Case-Smith's Occupational Therapy for

Children and Adolescents, 8e 8th

Edition Jane Clifford O'Brien
Visit to download the full and correct content document:
https://ebookmass.com/product/case-smiths-occupational-therapy-for-children-and-ad
olescents-8e-8th-edition-jane-clifford-obrien/
Case-Smith's
Occupational Therapy for
Children and Adolescents
EIGHTH EDITION

Jane Clifford O'Brien, PhD, OTR/L, FAOTA

Professor, Occupational Therapy Department, University of New England, Portland, ME, United States

Heather Kuhaneck, PhD, OTR/L, FAOTA

Associate Professor, Occupational Therapy Department, Sacred Heart University, Fairfield, CT, United States

1
Table of Contents
Cover image

Title page

Copyright

Dedication

Contributors

Reviewers

Preface

Acknowledgments

section 1. Foundational Knowledge for Occupational Therapy for Children and

Youth

1. The Occupational Therapy Process in Pediatrics: Overview of Essential Concepts

Introduction to Pediatric Occupational Therapy

The Process of Occupational Therapy

Pediatric Practice: Similarities and Differences to Adult Practice

Chapter 2. Using Occupational Therapy Models and Frames of Reference With Children and Youth

Introduction

Theory

Therapeutic Reasoning: Models and Frames of Reference

Occupational Therapy Models of Practice

Frames of Reference Used in Pediatric Occupational Therapy

Combining Frames of Reference

2
3. Working With Families

The Purpose and Power of Families

Family Resources and Diversity

Dynamic Family Systems and Occupations in Context

Family Subsystems

Family Life Cycle

Supporting Participation in Family Life

Families and The Interprofessional Team

Communication Strategies

Home Programs: Blending Therapy into Routines

Summary

4. Occupational Therapy View of Child Development

Human Development Through an Occupational Science Lens

Occupational Development Versus Skill Acquisition

Neurophysiological Development

Neurophysiological Growth and Occupational Development

Understanding Development Through Occupational Science Theories

5. The Intentional Relationship: Working With Children and Families

Introduction: Working with Families

Therapeutic Use of Self

The Intentional Relationship Model

Understanding Child and Family Interpersonal Characteristics

Inevitable Interpersonal Events

section 2. Occupational Therapy Assessment and Evaluation Methods and

Process

6. Observational Assessment and Activity Analysis

Activity Observation and Analysis

7. Use of Standardized Tests in Pediatric Practice

Purposes of Standardized Tests

3
 Becoming A Competent Test User

Types of Standardized Tests and Measures

Characteristics and Testing Mechanics

Scoring Methods

Ethical Consideration in Testing

Advantages and Disadvantages of Standarized Testing

8. Evaluation, Interpretation, and Goal Writing

What is evaluation?

Areas of Evaluation

Purpose of Evaluation

Top-Down Evaluation

Capturing The Parent’s and Child’s Perspective

Evaluation Process

Interpretation

Goal Writing

9. Documenting Outcomes

Introduction to Outcomes and Data Collection

Data Collection to Determine Efficacy of Services

section 3. Assessment and Treatment of Occupations

10. Assessment and Treatment of Feeding, Eating, and Swallowing

Feeding, Eating and Swallowing: Overview

Feeding Disorders: Incidence and Influences

Specialized Knowledge Required for Feeding and Swallowing Evaluation

Comprehensive Evaluation of the Development of Feeding and Swallowing

General Intervention Considerations

Case Application: Occupational Therapy Intervention Considerations

Chapter 11. Assessment and Treatment of Play

Introduction

Defining Play

4
 Theories of Play

Occupational Therapy’s Early Contributions to Play Literature

Impact of Play Deprivation

Leisure

Play and Leisure Assessment in Occupational Therapy

Play Goals

Play in Occupational Therapy Intervention

12. Assessment and Treatment of Activities of Daily Living, Sleep, Rest, and Sexuality

Importance of Deveoping Adl Occupations

Factors Affecting Performance

Evaluation of Activities of Daily Living

Intervention Strategies and Approaches

Specific Intervention Techniques for Selected Adl Tasks

Sleep and Rest

Education About Sleep and Rest

Summary

Chapter 13. Assessment and Treatment of Instrumental Activities of Daily Living and Leisure

Defining Instrumental Activities of Daily Living (IADL)

IADL Performance in Relationship to Participation

How Children Learn to Perform and Participate in Iadls

IADLs and Environment

Self-Determination and IADLs

Person, Environment, and Occupation Factors That Influence IADLs

Evaluation Approaches to Target IADLs

Intervention Approaches to Target IADLs

14. Assessment and Intervention of Social Participation and Social Skills

Overview of Social Participation

Environmental Influences on Social Participation

Outcomes of Successful Social Participation

Theoretical Basis of Social Skill Challenges

5
 Goals for Social Participation and Social Skills

Influence of Common Mental Health Conditions on Social Participation

15. Assessment and Treatment of Educational Performance

Education as an Occupation

Roles of the Student

The Occupational Therapy Evaluation Process in Schools

Interventions

Focused Areas of Intervention for Educational Performance

section 4. Occupational Therapy Approaches

16. Application of Motor Control and Motor Learning

Introduction

Motor Control and Motor Learning: Definitions

Overview of Guiding Theories

Principles of Motor Control

The Process of Motor Learning

Application of Motor Control/Learning Theory in Occupational Therapy Practice

17. Cognitive Interventions

Theoretical Foundations of Cognitive Approaches

Cognitive Strategies

Rationale for Using Cognitive Approaches

Cognitive Interventions

Cognitive Orientation to Daily Occupational Performance (CO-OP)

Evidence for Using Cognitive Approaches

18. Mobility

Mobility for Occupational Performance

Occupational Therapy Theory, Frame of Reference, and Models of Practice

Mobility is Complex and More Than a Physical Skill

Mobility Evaluation

Seating and Mobility Intervention

6
19. Assistive Technology

Introduction to Assistive Technology

Influencing Children’s Growth and Development with Assistive Technology

The Reasoning Process for AT

The AT Evaluation

Occupational Therapy Intervention and AT

Important Uses for AT

Specific Types of AT

Changing The Landscape in Education: Planning for Every Student in The Twenty-First Century

Technology Discontinuance or Abandonment

20. Sensory Integration

Introduction to Sensory Integration

When Problems in Sensory Integration Occur

Sensory Integration and Impact on Participation

Assessment of Sensory Integrative Functions

Interventions for Children with Sensory Integrative Problems

21. Behavioral Approaches

Introduction

Understanding Behavior

Interventions Based on Behavior Theory

section 5. Pediatric Occupational Therapy Services

22. Neonatal Intensive Care Unit

The Neonatal Intensive Care Unit in Broad Context

Occupational Roles of Infants and Caregivers in the NICU Setting

The Evolving NICU Care Environment

The NICU Patient

Foundations of Developmental Family-Integrative Care in the NICU

Neuroprotectoin of the Developing Brain and the NICU Caregiving Environment

Evaluation of the Infant

7
 Specific Therapeutic Interventions in the NICU

Partnering With Families in the NICU

Reflective Practice

23. Early Intervention Services

Definition and Purpose of Early Intervention Programs

Best Practices in Early Intervention

Occupational Therapy Early Intervention Practices

24. School-Based Occupational Therapy

Federal Legislation and State-Led Initiatives Influencing School-Based Practice

Occupational Therapy Services for Children and Youth in Schools

Occupational Therapy Services

School Mental Health: Emerging Roles for Occupational Therapy

25. Transition Services

Making the Transition to Young Adulthood

Additional Laws, Policies, and Trends Influencing Transition services

Seamless Transition: the Alignment of Outcomes

Evidence-Based Practices in Transition Services

26. Hospital and Pediatric Rehabilitation Services

Characteristics of Children’s Hospitals

Occupational Therapy Services for Children and Youth Within a Hospital

Acute Care Units

Rehabiltation Services

Outpatient Services

27. Pediatric Hand Therapy

Assessment

Intervention Principles and Strategies

Interventions for Specific Conditions

section 6. Occupational Therapy for Specific Conditions

8
28. Mental Health Conditions

Introduction to Childhood Mental HealtH Disorders

Mental Health Conditions of Children and Adolescents

Occupational Performance in Children with Mental Health Conditions

Caregiver Strain and Parent/Family Supports

Occupational Therapy Evaluation: Process

Strengths-Bases Occupational Therapy Intervention to Address Mental Health

Strength-Based Occupational Therapy Intervention to Address Mental Health

29. Neuromotor Conditions: Cerebral Palsy

Introduction

Evaluation Process and Methods

Medical-Based Interventions

Occupation-Focused Intervention for Children with Cerebral Palsy

30. Autism Spectrum Disorder

Introduction to Autism Spectrum Disorder

Occupational Performance in Autism Specturm Disorder

Autism Spectrum Disorder: Impact on the Family

The Role of Occupational Therapy in Autism Spectrum Disorder

31. Trauma-Induced Conditions

Introduction

Spinal Cord Injury

Traumatic Brain Injury

Burn Injury

Therapeutic Relationships

Posttrauma Occupational Therapy Assessment and Interventions

Interprofessional Team Collaboration

Posttrauma Continuum of Care

32. Vision Impairment

The Importance of Understanding Vision for Pediatric Occupational Therapists

Models of Vision

9
 Prevalence of Vision Problems in Children

Vision Screening for Occupational Therapists

Intervention

Vision Therapy Procedures

Appendix A

Index

10
Copyright
3251 Riverport Lane
St. Louis, Missouri 63043

OCCUPATIONAL THERAPY FOR CHILDREN AND ADOLESCENTS, EIGHTH EDITION ISBN: 978-
0-323-51263-3
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Copyright © 2015, 2010, 2005, 2001, 1996, 1989, 1985 by Mosby, Inc., an affiliate of Elsevier Inc.

No part of this publication may be reproduced or transmi ed in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,
editors or contributors for any injury and/or damage to persons or property as a ma er of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.

Previous editions Copyright © 2015, 2010, 2005, 2001, 1996, 1989, 1985 by Mosby, Inc., an affiliate of
Elsevier Inc.
Library of Congress Cataloging-in-Publication Data

Senior Content Strategist: Lauren Willis

Senior Content Development Manager: Lisa P. Newton
Publishing Services Manager: Deepthi Unni
Project Manager: Srividhya Vidhyashankar
Design Direction: Ryan Cook

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

11
Dedication

Dr. Jane Case-Smith was soft-spoken, thoughtful, and a brilliant scholar, who believed strongly in
using science as a foundation for intervention, while never overlooking the art of therapy. Her ability
to integrate these two important aspects of occupational therapy will forever influence the profession
and help many children and their families participate in daily occupations. Jane valued people,
consistently striving to foster strong relationships with her colleagues, coauthors, and the families
she served. She mentored many students, practitioners, and colleagues and her legacy exists in those
who will carry on the work she loved, including this text. Her spirit is infused throughout the
pictures and words of this book. Jane, we dedicate this edition that now carries your name in the title
to you, and hope you would be happy with the results.

12
Contributors
Beth Ann Ball, MS, OTR/L , Ohio OT, PT, AT Board, Chair , The Ohio State University ,
Occupational Therapy Program, Advisory Board Member, Columbus, OH, United States

Susan Bazyk, PhD, OTR/L, FAOTA , Director, Every Moment Counts, Professor Emerita,
Occupational Therapy, Cleveland State University, Cleveland, OH, United States

Rosemarie Bigsby, ScD, OTR/L, FAOTA , Clinical Professor of Pediatrics, Psychiatry and Human
Behavior, Warren Alpert Medical School, Coordinator, NICU Services, Brown Center for Children at
Risk, Department of Pediatrics, Women and Infant’s Hospital, Brown University, Providence, RI,
United States

Susan M. Cahill, PhD, OTR/L, FAOTA , Associate Professor & Program Director, Occupational
Therapy Program, Lewis University, Romeoville, IL, United States

Theresa Carlson Carroll, OTD, OTR/L , Clinical Assistant Professor, Occupational Therapy,
University of Illinois at Chicago, Chicago, IL, United States

Kaitlyn Carmichael, OT Reg. (Ont.) , School Health Occupational Therapist, Western University,
London, ON, Canada

Jana Cason, DHSc, OTR/L, FAOTA , Professor, Auerbach School of Occupational Therapy, Spalding
University, Louisville, KY, United States

Megan C. Chang, PhD, OTR/L , Associate Professor, College of Health and Human Sciences, San
Jose State University, San Jose, CA, United States

Gloria Frolek Clark, PhD, OTR/L, BCP, FAOTA , Owner, Gloria Frolek Clark, LLC, Adel, IA,
United States

Dennis Cleary, BA, BS, MS, OTD , Founding Program Director, Occupational Therapy, School of
Rehabilitative Science, Indiana University South Bend, South Bend, IN, United States,

Pa y Coker-Bolt, PhD, OTR/L, FAOTA , Professor, Medical University of South Carolina, Division
of Occupational Therapy, College of Health Professions, Charleston, SC, United States

Sharon M. Cosper, EdD, MHS, OTR/L , Associate Professor, Department of Occupational Therapy,
Augusta University, Augusta, GA, United States

Katherine Dimitropoulou, PhD, OTR/L , Assistant Professor, Department of Rehabilitation and

Regenerative Medicine, Occupational Therapy Program, Columbia University , New York, NY, United
States

Jenny M. Dorich, MBA, OTR/L, CHT , Occupational Therapist III , Division of Occupational
Therapy and Physical Therapy, Cincinnati Children’s Medical Center, Adjunct Faculty, College of
Health Sciences, University of Cincinnati, Cincinnati, OH, United States

Brian J. Dudgeon, PhD, OTR, FAOTA , Professor, retired, Occupational Therapy, School of Health
Professions, University of Alabama at Birmingham, Birmingham, AL, United States

13
Sarah E. Fabrizi, PhD OTR/L , Assistant Professor, Occupational Therapy Program, Florida Gulf
Coast University , Fort Myers, FL, United States

Patricia Fingerhut, PhD, OTR , Associate Professor and Chair, Robert K. Bing Distinguished
Professor, Distinguished Teaching Professor, Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, United States

Sandy Hanebrink, OTR/L, CLP, FAOTA , Executive Director , Touch the Future Inc, Anderson, SC,
United States

Karen Harpster, PhD, OTR/L , Assistant Professor, Division of Occupational Therapy and Physical
Therapy , Cincinnati Children’s Medical Center , College of Health Sciences, University of Cincinnati,
Cincinnati, OH, United States

Claudia List Hilton, PhD, MBA, OTR, FAOTA , Associate Professor of Occupational Therapy &
Rehabilitation Sciences, Distinguished Teaching Professor, University of Texas Medical Branch,
Galveston, TX, United States

Carole K. Ivey, PhD, OTR/L , Associate Professor, Department of Occupational Therapy, Virginia
Commonwealth University, Richmond, VA, United States

Lynn Jaffe, ScD, OTR/L, FAOTA , Professor & Program Director for Occupational Therapy ,
Department of Rehabilitation Sciences, Marieb College of Health & Human Services, Florida Gulf Coast
University, Fort Myers, FL, United States

Mary A. Khetani, Sc.D, OTR/L , Associate Professor, Department of Occupational Therapy, College
of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States

Kimberly Korth, MEd, OTR/L, SCFES , Occupational Therapist, Feeding Program Coordinator,
Children’s Hospital Colorado, Denver, CO, United States

Jessica Kramer, PhD, OTR/L , Associate Professor, Department of Occupational Therapy, College of
Public Health and Health Professions, University of Florida, Gainesville, FL

Heather Kuhaneck, PhD OTR/L FAOTA , Associate Professor, Occupational Therapy, Sacred Heart
University, Fairfield, CT, United States

Cheryl B. Lucas, EdD, OTR/L , Graduate Coordinator, Assistant Professor, Occupational Therapy
Department, Worcester State University, Worcester, MA, United States

Zoe Mailloux, OTD, OTR/L, FAOTA , Adjunct Associate Professor, Occupational Therapy, Thomas
Jefferson University, Philadelphia, PA, United States

Angela Mandich, PhD, OT Reg. (Ont.) , Director School of Occupational Therapy, Western
University, London, ON, Canada

Nancy Creskoff Maune, OTR/L , Occupational Therapist, Occupational Therapy, Feeding and
Swallowing Program, Children’s Hospital Colorado, Aurora, CO, United States

Christine T. Myers, PhD, OTR/L , Clinical Associate Professor and Program Director, Department
of Occupational Therapy, University of Florida, Gainesville, FL, United States

Erin Naber, PT, DPT , Senior Physical Therapist, Fairmount Rehabilitation Programs, Kennedy
Krieger Institute, Baltimore, MD, United States

Jane O’Brien, PhD, MS. EdL, OTR/L, FAOTA , Professor, Occupational Therapy, University of New
England, Portland, ME, United States

Shirley P. O’Brien, PhD, OTR/L, FAOTA , Foundation Professor, Department of Occupational

Science and Occupational Therapy, Eastern Kentucky University, Richmond, KY, United States

14
L. Diane Parham, PhD, OTR/L, FAOTA , Professor, Occupational Therapy Graduate Program,
University of New Mexico, Albuquerque, NM, United States

Andrew C. Persch, PhD, OTR/L, BCP , Assistant Professor, Department of Occupational Therapy,
Colorado State University, Fort Collins, CO, United States

Karen Ratcliff, PhD, OTR , Professor, Occupational Therapy, University of Texas Medical Branch
Galveston, Galveston, TX, United States

Teressa Garcia Reidy, MS, OTR/L , Fairmount Rehabilitation Programs, Hunter Nelson Sturge-
Weber Center, Kennedy Krieger Institute, Baltimore, MD, United States

Pamela Richardson, PhD, OTR/L, FAOTA , Interim Dean, College of Health and Human Sciences,
San Jose State University, San Jose, CA, United States

Lauren E. Rosen, PT, MPT, MSMS, ATP/SMS , Motion Analysis Center Program Coordinator, St.
Joseph’s Children’s Hospital, Tampa, FL, United States

Lisa Rotelli, PTA , Director, Adaptive Switch Laboratories, Austin, TX, United States

Andrina Sabet, PT, ATP , Cleveland Clinic Children’s Hospital for Rehabilitation, Mobility Ma ers,
LLC, Cleveland, OH, United States

Mitchell Scheiman, OD, PhD , Dean of Research and Sponsored Programs, Director of Graduate
Programs in Biomedicine, Professor, Salus University, Elkins Park, PA, United States

Colleen Schneck, ScD, OTR/L, FAOTA , Department Chair and Part-time Associate Dean, College
of Health Sciences, Department of Occupational Science and Occupational Therapy, Eastern Kentucky
University, Richmond, KY, United States

Judith Weenink Schoonover, MEd, OTR/L, ATP, FAOTA , Occupational Therapist, Assistive
Technology Professional, Specialized Instructional Facilitator-Assistive Technology, Loudoun County
Public Schools, Ashburn, VA, United States

Winifred Schul -Krohn, PhD, OTR/L, BCP, SWC, FAOTA , Professor and Chair of Occupational
Therapy, San Jose State University, San Jose, CA, United States

Pa i Sharp, OTD, MS, OTR/L , Occupational Therapist II, Division of Occupational Therapy and
Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States

Amber Sheehan, OTR/L , Occupational Therapist II, Division of Occupational Therapy and Physical
Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States

Jayne Shepherd, MS, OTR/L, FAOTA , Professor Emeritis, Department of Occupational Therapy,
Virginia Commonwealth Universitys, Richmond, VA, United States

Natasha Smet, OTD, OTR/L , Assistant Professor , Occupational Therapy , A.T. Still University ,
Mesa, AZ, United States

Susan L. Spi er, PhD, OTR/L , Owner/Director, Occupational Therapist, Private Practice, Pasadena,
CA, United States

Ashley Stoffel, OTD, OTR/L, FAOTA , Clinical Associate Professor, Department of Occupational
Therapy, University of Illinois at Chicago, Chicago, IL, United States

Kari J. Tanta, PhD, OTR/L, FAOTA

Rehab Manager, Children’s Therapy Program, Valley Medical Center, University of Washington
Medicine, Renton, WA, United States
Clinical Assistant Professor, Division of Occupational Therapy, Department of Rehabilitation Medicine,
University of Washington, Sea le, WA, United States

15
Renee R. Taylor, MA, PhD , Professor and Associate Dean for Academic Affairs, Licensed Clinical
Psychologist, Department of Occupational Therapy, College of Applied Health Sciences , 1919 W.
Taylor St. (MC 811), Chicago, IL, United States

Beth Warnken, OTD, OTR/L, ATP , Occupational Therapist II, Division of Occupational Therapy
and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States

Renee Watling, OTR/L, PhD, FAOTA , Visiting Assistant Professor, School of Occupational
Therapy, University of Puget Sound, Tacoma, WA, United States

Jessie Wilson, PhD, OT Reg. (Ont.) , Assistant Professor, School of Occupational Therapy, Western
University, London, ON, Canada

16
Reviewers
Meredith P. Gronski, OTD, OTR/L , Program Director and Chair, Methodist
University, Faye eville, NC, United States
Rebecca S. Herr, MOT, OTR , Instructor of Occupational Therapy, The
University of Findlay, Findlay, OH, United States
Diana Gantman Kraversky, OTD, MS, OTR/L, AP , Assistant Professor, West
Coast University, Los Angeles, CA, United States
Ann E. McDonald, PhD, OTR/L, SWC , Associate Professor, West Coast
University, Los Angeles, CA, United States
Deb McKernan-Ace, MOT/OTR, COTA , OTA Program Director, Bryant &
Stra on College, Wauwatosa, WI, United States

17
Preface

Organization
The current edition is organized into six sections to reflect the knowledge and skills needed to practice
occupational therapy with children and to help readers apply concepts to practice. The first section
describes foundational knowledge for occupational therapy for children and youth and includes
chapters on theories and practice models, child and adolescent development, family-centered care, and
therapeutic use of self.
The second section of the book focuses on the ability to evaluate and assess children and adolescents,
write goals, measure outcomes, and document progress from intervention. This section begins with a
chapter on the occupational therapist’s skill with observation and activity analysis as a primary method
of assessment. This is followed by an explanation of the use of standardized tests, including how to
administer a standardized test, score items, interpret test scores, and synthesize the findings.
Additional chapters provide information regarding the creation of goals and outcome measures based
on evaluation findings.
Section three highlights the specific assessment and intervention methods for each of the areas of
occupation. Chapters 10 to 15examine the assessment and treatment of feeding, play, activities of daily
living, instrumental activities of daily living, social participation, and educational performance. The
authors describe interventions to target performance areas (e.g., hand skills) and occupations (e.g.,
feeding, activities of daily living, play, social participation). Section four (Chapters 16 to 21) continues
with chapters related to specific intervention approaches used across areas of occupation. The authors
describe a variety of intervention approaches, including motor control/motor learning, cognitive,
mobility, assistive technology, sensory integration, and behavioral. The authors explain both the theory
and science of occupational therapy practice and discuss issues that frequently occur in practice.
Together these chapters reflect the breadth and depth of occupational therapy with children and
adolescents.
The fifth section (Chapters 22 to 27) of the book describes the specific contexts of occupational
therapy practice with children. These chapters illustrate the rich variety of practice opportunities and
define how practice differs in medical versus education systems and institutions. Only by
understanding the intervention context and the child’s environments can occupational therapists select
appropriate intervention practices.
The final and sixth section, (Chapters 28 to 32) provide readers with strategies for specific
populations. For example, the chapters illustrate how practitioners help children with mental health
disorders, including neuromotor conditions such as cerebral palsy, autism, trauma-induced conditions,
or visual impairments, engage in occupations.

Distinctive Features
Although the chapters contain related information, each chapter stands on its own, such that the
chapters do not need to be read in a particular sequence. Each chapter begins with key questions to
guide reading. Case reports exemplify concepts related to the chapter and are designed to help the
reader integrate the material. Research literature is cited and used throughout. The goal of the authors
is to provide comprehensive, research-based, current information that can guide practitioners in
making optimal decisions in their practice with children.
Distinctive features of the book include the following:

18
 • Research Notes
• Evidence-based summary tables for intervention specific chapters
• Case Studies

Ancillary Materials
The Case-Smith’s Occupational Therapy for Children and Adolescents text is linked to an Evolve website that
provides a number of learning aids and tools. The Evolve website provides resources for each chapter,
including the following:

• Video clips with guiding questions

• Additional case studies with guiding questions to reinforce chapter content
• Learning activities
• Multiple choice questions for students and faculty
• Resources (such as forms and handouts)
• Glossary

The Evolve learning activities and video clip case studies relate directly to the text; it is hoped that
readers use the two resources together. In addition, readers are encouraged to access the Evolve
website for supplemental information.

19
Acknowledgments
We would like to thank all the children who are featured in the video clips and case studies:

Adam
Ana
Annabelle
Camerias
Christian
Christina
Eily
Ema
Emily
Emily
Faith
Isabel
Jessica
Jillian
Katelyn
Luke
Ma
Micah
Nathan
Nathaniel
Nicholas
Paige
Peggy
Samuel
Sydney
Teagan
Tiandra
William
Zane

A special thank you to the parents who so openly shared their stories with us:

Charlie and Emily Adams

Robert and Carrie Beyer
Freda Michelle Bowen
Nancy Bowen
Kelly Brandewe
Ernesty Burton
Ruby Burton
Lori Chirakus
Joy Cline
Sondra Diop
Lisa M. Grant
Ivonne Hernandez

20
 Shawn Holden
Luann Hoover
Sandra Jordan
Joanna L. McCoy
Maureen P. McGlove
Jill McQuaid
Stephanie L. Mills
David J. Petras
Theresa A. Philbrick
Ann Ramsey
Teresa Reynolds-Armstrong
Tuesday A. Ryanhart
Julana Schu
P. Allen Shroyer
Douglas Warburton

We are very appreciative of the siblings and buddies who agreed to help us out:

Aidan
Lori
Megan
Robert
Todd and Keith
Tommy, Owen, and Colin

We thank all the therapists and physicians who allowed us to videotape their sessions and provided
us with such wonderful examples:

Chrissy Alex
Sandy Antoszewski
Mary Elizabeth F. Bracy
Amanda Cousiko
Emily de los Reyes
Katie Finnegan
Karen Harpster
Terri Heaphy
Katherine Inamura
Lisa A. King
Dara Krynicki
Marianne Mayhan
Taylor Moody
Julie Po s
Ann Ramsey
Suellen Sharp
Carrie Taylor

A special thanks to Ma Meindl, Melissa Hussey, David Stwarka Jennifer Cohn, Stephanie Cohn, and
all the authors who submi ed videotapes. Thank you to Emily Krams, Alicen Johnson, Britanny Peters,
Katherine Paulaski, Carol Lambdin Pa avina, Sco McNeil, Alison O’Brien, MaryBeth Patnaude, Molly
O’Brien, Keely Heidtman, Greg Lapointe, Caitlin Cassis, Judith Cohn, Jazmin Photography, Michelle
Lapelle, Stacie Townsend, and Barbara Price. A special thanks to Mariana D’Amico, Peter Goldberg,
and Carrie Beyer for all their expertise with videotaping. Lisa Newton and Lauren Willis were
instrumental in developing and completing this text and were a pleasure with whom to work. Thank
you to Srividhya Vidhyashankar for finalizing the pages and supporting us.
Jane O’Brien would like to thank her family—Mike, Sco , Alison, and Molly—for their continual
support. Thank you to my colleagues and students at the University of New England, the children and

21
families who provided inspiration for the material, and Heather Kuhaneck for her expertise, support,
and ability to keep the process fun.
Heather Kuhaneck would like to thank her family, in particular, her husband, Shayne, for his
unwavering support. Thank you to Jane O’Brien for making my transition into this process as smooth
as possible. Thank you also to Malia Norman and Jeffrey Homan, student assistants who gathered
articles, checked citations, and generally made things easier. Lastly, thank you to my Sacred Heart
colleagues, students, and alum for all of their help and support.
We both thank all the authors for their willingness to share their expertise, labor, and time in
producing excellent chapters. And finally, we both would like to express our appreciation to Jane Case-
Smith for leaving us with such an excellent text to start with and such an amazing group of authors
with whom to work.

22
SECTION 1

Foundational Knowledge for

Occupational Therapy for
Children and Youth
OUTLINE

1. The Occupational Therapy Process in Pediatrics

Chapter 2. Using Occupational Therapy Models and Frames of Reference With Children and
Youth
3. Working With Families
4. Occupational Therapy View of Child Development
5. The Intentional Relationship

23
1

The Occupational Therapy

Process in Pediatrics
Overview of Essential Concepts
Heather Kuhaneck, and Jane Case-Smith

GUIDING QUESTIONS
1. How are occupational therapy principles and practices applied to pediatrics?
2. What are the key characteristics of pediatric practice?
3. How does the pediatric occupational therapist function across varied environments and settings?

KEY TERMS
Adulthood
Bo om-up
Childhood
Cultural competence
Family-centered care
Inclusion
Just-right challenge
Occupations
Self-efficacy
Self-determination
Standardized assessment
Top-down
Therapeutic use of self

Introduction to Pediatric Occupational Therapy

This text is devoted to pediatric occupational therapy practice. Each chapter highlights a specific aspect
of practice so that the roles, tasks, clients, assessment and intervention methods, and se ings of
pediatric practice can be more clearly understood. In actuality, however, there is significant overlap in
how the occupational therapist uses the information provided in each chapter. There are also key
features of pediatric practice that transcend the boundaries provided by the chapter titles and focus.
This chapter provides an overview of those key features and highlights important concepts that are

24
presented across multiple chapters to clarify the similarities and differences between pediatric practice
and other practice areas.

What Is Pediatric Practice?

Pediatric practice refers to occupational therapy with infants, toddlers, children, and youth and ends
with the period of adulthood. Both childhood and adulthood are socially and culturally defined
constructs. In the United States, childhood is commonly considered to be between birth and age 18, when
a child officially becomes an adult in the eyes of many laws. Adulthood is legally defined as the age of
majority, which is defined by the states. However, many adult tasks are allowed at varied ages in
different states, so the issues of, “What is childhood?” and “What is adulthood?” have become blurred.
Adult activities are often considered driving, voting, military enlistment, marriage, work, and the use of
legal substances such as alcohol and cigare es. Some of these adult activities are allowed as young as 14
to 16 years of age and others not until 21. Biologically, adulthood begins with puberty, but even puberty
occurs at different ages for different individuals. And if one considers skeletal development, the last
bone to develop occurs at about age 25 (Smithsonian, 2018). Childhood and adulthood are therefore
somewhat “fuzzy” concepts.
For many occupational therapists, the boundaries of their “pediatric” practice are defined by law. The
Individuals with Disabilities Education Improvement Act of 2004 (IDEA) states that for individuals
receiving special education, services end at age 21. The American Occupational Therapy Association
(AOTA) generally follows this convention, typically suggesting that pediatric practice with children and
youth occurs from birth to age 21 (AOTA, 2018c). Ideally, pediatric occupational therapy practice assists
children and families in preparing for and a aining adult roles and a satisfying and meaningful adult
life.

Pediatric Practice Within the Profession of Occupational Therapy

The recent practice analysis by the National Board for Certification in Occupational Therapy (NBCOT;
2018) suggests that pediatric practice is now the largest practice area, edging out skilled nursing
facilities by a fraction of a percent, as of the 2017 survey, with 20% of occupational therapists working in
pediatric practice. Of those responding, 15% specified that they worked in the school system (NBCOT,
2018). And while many occupational therapists change practice areas during their career, school-based
practice is one of the areas with less turnover (AOTA, 2018a). Therefore education regarding pediatric
practice, and school-based practice in particular, is important for entry level education. The information
provided throughout this textbook aims to prepare entry level students, or occupational therapists
about to change practice areas, with the information necessary to begin occupational therapy practice in
varied se ings, with both children and their families.

Philosophy of Occupational Therapy and Essential Concepts for

Pediatric Practice
Occupational therapists believe that occupation both brings meaning to and has the power to influence
the health of human beings (AOTA, 2011). Occupation occurs across the lifespan and in diverse contexts,
and each person’s experiences of occupation across his or her life trajectory is unique. Although it has
been difficult for the profession to agree on one single definition of occupation, a variety of properties
have been associated with human occupation. Occupations are meaningful, goal directed/purposeful,
provide personal satisfaction, occur over time, may or may not be observed by others, and occur within
the contexts of daily life (AOTA, 2014a). Occupations may be completed with others, and as such are
then called co-occupations. Occupations have been categorized in the United States to include activities
of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work,
play, leisure, and social participation (AOTA, 2014a). These conceptualizations of occupation, however,
have been developed, described, and explored primarily in western cultures and may not fully adapt to
or fit with other cultural views and experiences (Iwama, 2003). What will be described in this chapter
and throughout most of this text is practice in the United States. The primary goal or outcome of
occupational therapy is to assist our clients in “achieving health, well-being, and participation in life
through engagement in occupation” (AOTA, 2014a, p S4). In order to be best able to do this for children,
the pediatric occupational therapist must engage in family-centered care, using a strength-based focus,
situated within a practice that is culturally competent.

25
Family-Centered Care
Family-centered care is identified throughout this text as a key feature of pediatric practice. Multiple
components of family-centered care have been identified including open communication, mutual trust
and respect, the sharing of information with parents and families to allow shared decision making, and
the consideration and incorporation of family preferences and needs into intervention ( Almasri, An, &
Palisano, 2018; An, & Palisano, 2014; King, & Chiarello, 2014; Kuo et al. , 2012). Recently, the literature
has been reviewed and concepts distilled into three primary core beliefs: (1) respect for children and
families; (2) appreciation of the family’s impact on the child’s well-being; and (3) family-professional
collaboration (King, & Chiarello, 2014).
Multiple studies using qualitative methods and surveys have investigated what parents want from
service providers. Parents of children with Down syndrome, cerebral palsy, autism, and other
developmental and neurological disabilities state that what they seek from therapists is (1) a true
partnership; (2) a dependable resource for specific, objective information; (3) flexibility in service
delivery and in communication style; (4) sensitivity and responsiveness to their concerns; (5) positive,
optimistic a itudes; and (6) effectiveness in generating outcomes ( Bailes et al., 2018; Case-Smith et al.
2007; Edwards, Brebner, Mccormack, & Macdougall, 2016; Hayles, Harvey, Plummer, & Jones, 2015;
Kruijsen-Terpstra et al, 2014; Marshall, Tanner, Kozyr, & Kirby, 2015; McWilliam, Tocci, L., & Harbin,
1998; Scime, Bartle , Brunton, & Palisano, 2017 ). Parental satisfaction with services may be most related
to their relative feelings of self-efficacy in the situation and their opinion regarding the purpose of the
services that they have received (Robert, Leblanc, & Boyer, 2015), making the partnership between
therapist and parent even more important.
Additional important components of family-centered intervention include respecting parents’
knowledge of their child, acknowledging their resilience, accepting their values, and facilitating the
building of a network of social resources (Dunst, & Dempsey, 2007). In a meta-analysis of family-
centered practice in early intervention service, two types of family-centered services were identified: (1)
services that fostered positive professional-family relationships and (2) services that enabled the
family’s participation in intervention activities (Dunst, & Dempsey, 2007). In relationship building
practices, occupational therapists actively listen, show compassion and respect, and believe in the
family’s capabilities. Occupational therapists enable and promote the family’s participation by
individualizing their services, demonstrating flexibility in meeting family needs, and being responsive
to family concerns. Dunst, Trive e, and Hamby (2007) found that the provision of family-centered
services was highly related to the family’s self-efficacy beliefs, parents’ satisfaction with the program,
parenting behaviors, and child behavior and functioning.
Parents report that they want family-centered care (which results in be er outcomes) but recent
national surveys suggest that not all parents receive services that are family-centered and significant
regional, geographic, and socioeconomic disparities exist (Almasri, An, & Palisano, 2018; Azuine, Singh,
Ghandour, & Kogan, 2015; Kuo et al 2012). An occupational therapist’s or organization’s use of family
centered care can be evaluated through three primary areas, context, process, and outcomes (Arango,
2011) (Table 1.1). Reviews of literature across many years suggest that some aspects of family-centered
care are managed well, such as the provision of services in respectful partnerships with families, but
other areas, such as providing information to parents and families, are not routinely family-centered
(Cunningham & Rosenbaum, 2014). This suggests that professionals may need to do a be er job of
providing some aspects of family-centered care and may need to specifically evaluate their own services
to determine if they are practicing family-centered care with clients. See Appendix A for assessment
tools to evaluate family-centered care. Chapter 3 provides more information on this topic.

Strength-Based Focus
Children and youth with disabilities often have unique strengths that are overlooked by others, but if
these strengths are identified and encouraged, they can lead to increased participation. Occupational
therapists evaluate the strengths of a child or youth in addition to trying to understand their difficulties
and challenges. Interventions in pediatric occupational therapy build on those strengths. By identifying
the positive aspects of a child’s behavior and areas of greatest competence as well as performance
limitations, occupational therapists can reframe the child’s behavior for his or her parents, allowing
caregivers to see the child in a new light. For example, focusing on strengths in communication about a
child during parent education for parents of autism led to parents displaying more positive affect,
making more positive statements about their child, and exhibiting greater physical affection toward

26
their child (Steiner, 2011). As explained throughout this text, strength-based approaches can lead to
increased self-efficacy and self-determination for the child.

Table 1.1

Components of Family Centered Care Evaluation

Table based on information provided in Almasri, An, & Palisano, 2018; Arango, 2011; Dunst, 2002; Schreiber et al.,
2011.
The strength-based model contrasts with the traditional medical model, which focuses intervention
on identifying the health or performance problem and resolving that problem. As explained in many
chapters of this book, focusing on a child’s performance problem does not always lead to optimal
participation and improved quality of life. Because occupational therapists are concerned with a child’s
full participation in life activities, focusing solely on impairment narrows the vision of what the child
can become and do.
Although a strength-based approach is often recommended, it may be more difficult to note in
practice. For example, research suggests that the occupational therapist’s documentation may be more
frequently wri en with a deficit focus (Braun, Dunn, & Tomchek, 2017). Pediatric occupational
therapists must emphasize a strength-based approach throughout all aspects of the occupational
therapy process to fully embrace the potential of this approach to produce positive changes for families
and pediatric clients. Case 1.1 provides an example of using a strength-based focus with a child with
autism.

Case 1.1 A Strength-Based Approach with a Child Who Has High-

Functioning Autism
Victor is a 10-year-old boy with high-functioning autism. He has extraordinary visual perceptual skills
and visual memory; he also has significant delays in social skills. In particular, he has difficulty
knowing how to interact with his peers on the playground or in unstructured social activities. The
therapist, Amy, suggests that he video record his peers when they are playing together or talking on the
playground. Using these videos, Victor has examples of appropriate social interactions. He and Amy
analyze the videos together, discussing how the children initiate and respond to social interaction; he
practices some of the interactions with Amy. Amy encourages him to watch the examples of positive
social interactions a number of times.
Using the videos, Victor makes and labels photographs of different examples of social interactions.
With Amy’s help, Victor organizes the photographs into stories that he uses to learn how to engage
with others socially. Amy also helps him organize the photographs into a social story; she creates a
visual step-by-step procedure for initiating a social interaction.
The other children were interested in his videos and stories; they read the stories and praised Victor’s
skills in video recording and photography. His interest in and talents for photography resulted in a
sequence of naturally occurring social interactions that allowed Victor to practice the social skills. By
using a strength-based approach, he not only had used his talents to learn new skills, but also his peers
recognized and appreciated his talent, establishing enhanced contexts for social participation.
Adapted from Bianco, Carothers, & Smiley.10

Cultural Competence
Cultural competence means that the pediatric occupational therapist is able to practice effectively with
clients from a different cultural group. A system that provides “culturally competent” care is one that
“acknowledges and incorporates—at all levels—the importance of culture, assessment of cross-cultural
relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural
knowledge, and adaptation of services to meet culturally unique needs” (Betancourt, Green, Carrillo, &

27
Owusu Ananeh-Firempong, 2016 pp 294). A culturally competent therapist must be open to exploring
differences, valuing the client’s unique perspectives and expertise, and engaging in self-reflection about
the impact of his or her own culture on his or her practices as an occupational therapist. Recent research
suggests that important antecedents to cultural competence include openness, awareness, desire,
sensitivity, and knowledge (Henderson, Horne, Hills, & Kendall, 2018).
Specific practices to engage in to provide culturally competent care include many of the behaviors
identified as family-centered care, including building a collaborative partnership with the family,
understanding the specific situation of the family, and then tailoring therapy to that specific situation. In
addition, for culturally competent care, the therapist must ensure that the parents understand all
information provided and specifically understand the specific therapeutic procedures (King, Desmarais,
Lindsay, Piérart, & Tétreault, 2015). Other specific strategies identified by occupational therapists
working with immigrant parents of children with disabilities include those that helped overcome a
language barrier, those that helped develop a shared understanding regarding the child’s disability, and
those that assisted the parents in understanding the process of intervention (Brassart, Prévost, Bétrisey,
Lemieux, & Desmarais, 2017). The outcomes of cultural competence include client satisfaction with care,
greater perception of quality care, be er adherence, more effective interaction, as well as improved
outcomes (Henderson, Horne, Hills, & Kendall, 2018).
A child’s occupations are embedded in the cultural practices of his or her family and community.
Pediatric occupational therapists need to be aware of the potential for cultural differences in family
makeup, parenting practices, expectations for child behavior and autonomy, engagement with health
professionals, as well as the impact of race, ethnicity, and culture on child outcomes, overall health, and
well-being of families (Campos, & Kim, 2017; Fi gerald, 2004; Rowe, Denmark, Harden, & Stapleton,
2016 ). See Table 1.2 for specific questions to consider in relation to family culture and family
occupations. Culture impacts family and the occupations of the family and the child. For example, a
family’s culture may make it more or less likely for those family members to encourage independence
for a child or to want to do things for a child. Families are extremely diverse but may often be judged by
professionals when they do not conform to the typical standards of the dominant culture (Fi gerald,
2004). Parenting style ma ers and can have an impact on long-term childhood outcomes (Castro et al.,
2015; Pinquart, 2017); however cultural differences in parenting may be only a small part of the impact
(Pinquart & Kauser, 2018). Pediatric occupational therapists must take care not to judge the parenting
styles of others based on their own notions of parenting.
For occupational therapists in the United States, cultural competence is critical as the diversity of the
United States continues to increase and the makeup of the population is changing. In 2016, 43.7 million
immigrants were living in the United States, which was 13.5% of the population (Radford & Budimen,
2018). Asian Americans and Latino/a Americans comprise the two largest and fastest growing groups in
the United States (Radford & Budimen, 2018; U.S. Census Bureau, 2010) with Asia surpassing Latin
America as the number one source of new immigration (Cohn & Caumont, 2016). However, change in
the country is not evenly dispersed.
Depending on where the occupational therapist works, he or she may be more or less exposed to
different cultures and/or immigrant populations and the changes may happen more slowly or quite
rapidly ( Keating & Karklis, 2016; MPI, 2018). For example, a large population of Hmong migrated to the
Minneapolis–St. Paul region in a relatively brief period of time, requiring the health professionals of that
area to rapidly learn to provide care to a new culture (Stratis Health, 2012; Williams, 2011). Culturally
competent pediatric occupational therapists must be a une to these types of regional changes and do
what is necessary to provide culturally competent care to any new population of immigrants.

28
Table 1.2

Cultural Values and Styles That Influence Children’s Development of Occupations

Value or Style Guiding Questions
Family composition Who are the members of the family? How many family members live in the same house? Is
there a hierarchy in the family based on gender or age?
Decision making Who makes the decisions for the family?
Primary caregiver Who is the primary caregiver? Is this role shared?
Independence/interdependence Do family members value independence?
Feeding practices Who feeds the infant or child? What are the cultural rules or norms about breastfeeding,
mealtime, self-feeding, and eating certain foods? When is independence in feeding expected?
Sleeping pa erns Do children sleep with parents? How do parents respond to the infant during the night? What
are appropriate responses to crying?
Discipline Is disobedience tolerated? How strict are the rules governing behavior? Who disciplines the
child? How do the parents discipline the child?
Perception of disability Do the parents believe that the disability can improve? Do they feel responsible for the
disability? Do family members feel that they can make a difference in improving the
disability? Are spiritual forms of healing valued?
Help seeking From whom does the family seek help? Does the family actively seek help, or do family
members expect help to come to them?
Communication and Does the family use a direct or an indirect style of communication? Do family members share
interaction emotional feelings? Is most communication direct or indirect? Does the family value
socializing?

Adapted from Wayman, K. I., Lynch, E. W., & Hanson, M. J. (1990). Home-based early childhood services:
cultural sensitivity in a family systems approach. Topics in Early Childhood Special Education, 10, 65–66.

Pediatric occupational therapists must also understand the extent of actual disparities in healthcare
and the consequences of those disparities ( Barr, 2014; Goodman, Gilbert, Hudson, Milam, & Coldi ,
2017; National Center for Health Statistics US, 2016; Paradies et al., 2015 ). Health disparities have been
found for a multitude of conditions and diseases, including birth weight and cancer, as well as overall
mortality (Barr, 2014). Although much of the literature on health care disparities centers on adults, a
recent review found that disparities exist for children as well (Ridgeway et al., 2017).
Child health is different from adult health, “as summarised in the five D’s: developmental change,
dependency on adults, differential epidemiology, demographic pa erns, and dollars” (Ridgeway et al,
2017 p. 2). In children, the data supports that disparities exist for cancer and asthma as well as unequal
access to care. Disparities also exist in the provision of therapy services. Using national data, the
percentage of children with unmet therapy needs was different for black, Hispanic, and white children
(Magnusson & Mistry, 2017).
Engaging in evidence-based practice, the pediatric occupational therapist also needs to consider the
evidence of healthcare disparities carefully in relation to race, ethnicity, culture, and socioeconomic
status. Although in the United States people are often classified by either race, ethnicity, or both, in
reality there is overlap between race and ethnicity as both consider ancestry in the way the concept is
defined (Barr, 2014). The use of race to examine outcomes in healthcare is controversial and ethnicity
may be more important to cultural practices and health outcomes than the more broad designation of
race (Barr, 2014). Sorting people into categories of any type is influenced by the social conventions of the
time (Barr, 2014), and in the United States both race and ethnicity can be associated with
socioeconomics. Therefore in examining the impact of race and ethnicity of health and outcomes in
research, there are many confounding factors.
There are many barriers that hinder equal access to healthcare. These barriers have been identified as
organization and institutional, structural, and clinical (Betancourt et al, 2003). Specifically, barriers
include the lack of diversity in healthcare workers, educators, and leaders, language barriers and lack of
interpreters, access to specialists in certain areas or regions, and poor communication and a itudinal
barriers. One method available to pediatric occupational therapists to a empt to address unequal
regional access to services is telehealth (Marcin, Shaikh & Steinhorn, 2015).

Therapeutic Use of Self and Relationship Building

One definition of therapeutic use of self is the “planned use of [a therapist’s] personality, insights,
perceptions, and judgments as part of the therapeutic process” (Punwar & Peloquin, 2000, p. 285; Taylor,
Lee, Kielhofner, & Ketkar, 2009). Therapists believe that therapeutic use of self is important to their

29
practice and to the outcomes they achieve with clients (Taylor, Lee, Kielhofner, & Ketkar, 2009). The
Intentional Relationship Model (see h p://irm.ahslabs.uic.edu/what-is-the-irm/) provides a structure for
examining the therapist- client relationship. Although much of the research on the model to date is with
adults, the model can be applied to pediatric practice (see Chapter 5 for further description of the model
and its application to children).
As described throughout this text, the therapeutic relationship with a child is critical for the success of
pediatric occupational therapy. The pediatric occupational therapist establishes a relationship with the
child that encourages, supports, and motivates. In order to do so, the occupational therapist first creates
trust. This trust enables the child to feel safe and to be willing to take risks. The therapeutic relationship
involves respecting the child’s emotions and creating a climate of emotional safety. Occupational
therapists demonstrate a positive affect and seek opportunities for personal connection while conveying
positive regard. The occupational therapist shows interest in the child, makes efforts to enjoy his or her
personality, and values his or her preferences and goals.
Similarly, trust building between professionals and family members is a first step in building a
relationship. Demonstrating mutual respect, being positive, and maintaining a nonjudgmental position
with a family creates trust. Occupational therapists cultivate positive relationships with families when
they establish open and honest communication and encourage participation of parents in their child’s
program to the extent that they desire.
Many of the concepts of the therapeutic alliance that have been adopted throughout pediatric practice
originated in the intervention methods of sensory integration (see Chapter 20). These include the ideas
that it is important to collaborate with a child on activity choice, the therapist must ensure success, and
support intrinsic motivation as well as the concept of presenting the “just-right challenge” (Parham
et al., 2011). These concepts are discussed in the following sections and chapters.

The Process of Occupational Therapy

The process of occupational therapy includes the completion of an occupational profile, an analysis of
occupational performance, and then, if warranted, the creation and implementation of an intervention
plan (AOTA, 2014a). A critical feature of “best practice” is the use of evidence to guide the intervention
plan as well as the routine gathering of documentation to measure desired outcomes. All occupational
therapy is client-centered and strives to help the client achieve important and meaningful goals through
collaboration and inclusion of the client in all aspects of service delivery with shared decision making to
the extent possible. Throughout all aspect of the pediatric process, the occupational therapist uses
theory to guide clinical reasoning.

Use of Theory and Clinical Reasoning

Pediatric occupational therapists use theory from within and outside of the profession of occupational
therapy to enhance their understanding of children and their behaviors. They use both occupation-
centered models of practice and frames of reference as underpinnings of their clinical reasoning during
assessment and intervention. The models of practice provide a structure to evaluate children and youth
by examining the interactions between person, environment, and occupation. Frames of reference
provide specific strategies and techniques to intervene with children and youth. Both are theoretically
derived. See Chapter 2 for more detail on the use of models and frames of reference used in pediatric
practice. Clinical reasoning for decision making is covered throughout the chapters of this text. Specific
interventions associated with frames of reference are also considered in Chapters 16, 17, 20, and 21.

Pediatric Occupational Therapy Evaluation: Essential Concepts

Top-Down and Bottom-Up
As a profession, occupational therapy has moved towards the adoption of a top-down approach to
evaluation (AOTA, 2014). Many of the chapter authors recommend using a top-down approach to
assessment. A therapist using a top-down approach begins the evaluation process by gaining an
understanding of the child’s level of participation in daily occupations and routines with family, other
caregiving adults, and peers. The examination of specific skills and client factors come later.
Alternatively, a therapist using a bo om-up approach first evaluates client factors to understand what
might be limiting a child’s performance skills and occupational performance. Often the decisions about
which client factors to assess are related to the child’s diagnosis and expected areas of difficulty (see

30
Chapters 28, 29, 30, 31, and 32). In this type of approach, the therapist might examine strength and range
of motion, or manipulation skills first. The assumption is that deficits in these skills will hinder
performance in functional tasks such as coloring or bu oning and therefore limit performance in
broader occupations of ADLs and education.
However, some authors argue for the importance of both types of assessment approaches and a
combined approach (Scho , Holfelder, & Mousouli, 2014; Weinstock-Zlotnick & Hinojosa, 2004). There
is some level of agreement but not total agreement between evaluation results obtained either way
(Kennedy, Brown, & Stagni i, 2013; Scho , Holfelder, & Mousouli, 2014)). Children appear to provide a
source of information that differs from that provided by parents, teachers, and direct observation
(Brown, 2012; Kennedy, Brown, & Chien, 2012; Lalor, Brown, & Murdolo, 2016). Therefore whichever
approach is adopted, occupational therapists are encouraged to seek information from a variety of
informants and methods.

Use of Multiple Methods

A comprehensive evaluation of a child requires the use of a variety of tools and methods (Coster &
Frolek-Clark, 2013). Multiple chapters in this text provide information regarding completion of
assessment through parent or teacher interview, child self-report, observation of performance using the
skill of activity analysis, and the use of standardized assessment tools. Each method may provide
different information and the use of multiple methods of assessment is recommended (Diamantis, 2008;
Fisher, Griswold, Munkholm, & Ko orp, 2017; Laver Fawce , 2014; Nielsen & Wæhrens, 2015;
Waehrens, Bliddal, Danneskiold-Samsøe, Lund, & Fisher, 2012).
Standardized assessments are tests that require a specific method of administration for every individual
and that specify a set scoring method. Standardized assessment is often used for a variety of reasons
including descriptive, predictive, discriminative, and evaluative purposes (Laver Fawce , 2014).
Occupational therapy evaluations are often descriptive in nature, providing information about an
individual’s history, current context, level of occupational performance and participation, skills,
strengths, and deficits, and the individual’s roles, habits, and routines. This type of assessment often
assists in diagnosis or uncovers contextual barriers or facilitators of performance. Data from this type of
assessment is used to develop an intervention plan (Laver Fawce , 2014).
Although the use of standardized measures for assessment is more common and is often
recommended as best practice, many therapists still do not use these tools for a variety of reasons (
Colquhoun et al., 2017; O’Connor, Kerr, Shields, & Imms, 2016, 2017). In one study, therapists reported
that they were unable to use standardized measures because of limited availability or that they were
unwilling to because of their perceptions of the tool’s applicability (O’Connor, Kerr, Shields, & Imms,
2017). Other therapists reported the complexity and time requirements for scoring some of the tools as a
potential barrier to their use. Still others noted the difficulty in using standardized assessments with
children with more severe cognitive and language delays.
The most commonly reported standardized assessment tools used by occupational therapists
included the Peabody Developmental Motor Scales, the Bruininks Oseretsky Test of Motor Performance,
and the Test of Visual Motor Integration ( Piernik-Yoder & Beck, 2012; O’Connor, Kerr, Shields, & Imms,
2016). Although results from these types of measures do not necessarily equate to functional
performance ( Case-Smith, 1995; Coster & Frolek-Clark, 2013; Rodger et al., 2003 ), when used in a top-
down approach, they may be helpful to a empt to explain difficulties found in occupational
performance and participation. Appendix A presents a comprehensive list of assessments used in
pediatric practice.
Pediatric therapists select methods and tools to meet the needs of the child and situation to obtain the
necessary information required for the purpose of the evaluation. The decision to use standardized
testing in addition to observation and interview should be made by making a good match between the
tools that are available, and their reliability as well as their validity for the chosen purpose. The
processes of pediatric occupational therapy evaluation, and the varied methods are further discussed in
Chapters 6, 7, 8, and 9.

Importance of Context
The pediatric occupational therapist considers how the environment influences performance and
completes observations of the child in the child’s natural environment. Occupational therapists evaluate
the contexts in which the child learns, plays, and interacts. Evaluating performance in multiple contexts
(e.g., home, school, childcare center, community se ing) allows the occupational therapist to appreciate

31
how different contexts affect the child’s performance and participation. By considering the child’s
performance in the context of physical and social demands, assessment in natural environments helps
determine the discrepancy between the child’s actual performance and expected performance. The
occupational therapist considers cultural influences, resources, and value systems of the child’s family
context. The occupational therapist also considers the fit or match between the performance of the child
or youth and the demands and expectations of the environment (e.g., in school-based practice, the
relationship between the child’s performance and the educational context and curriculum). To support
adolescents preparing for employment, occupational therapists consider the adolescent’s performance
as it relates to specific job tasks and work contexts. Through in-depth task analysis and performance
analysis, the occupational therapist identifies the skills required for the job tasks and the discrepancy
between the task requirements and the youth’s performance. If the team seeks to identify the student’s
interests and abilities as they relate to future community living, the assessment takes place in the
community and the home.
Research suggests a variety of contextual barriers that hinder participation for students with
disabilities (Anaby et al., 2013; Anaby et al., 2014; Coster et al., 2013; Law et al., 2013). Barriers include
physical barriers that limit access and mobility, such as lack of equipment, lack of transportation,
inadequate parking or ramps for wheelchairs, or lack of elevators. A itudinal barriers also exist, such as
overprotectiveness, family values in relation to independence, stigma, and bullying in the community.
Policy barriers include lack of programs, lack of flexibility, segregation, or financial hardship due to
program/services costs.
Standardized assessments of context are available (Coster et al., 2011; Khetani, 2015; Khetani, Graham,
Davies, Law, & Simeonsson, 2015; McCauley et al., 2013). Many of these tools are relatively new and
need to become more routinely used by pediatric occupational therapists. Often the occupational
therapist evaluates contextual factors informally through observation. (See Chapter 6 for more
information and see Tables 1.2 and 1.3 for guiding questions to frame observation of context).

Pediatric Occupational Therapy Intervention: Essential Concepts

Many chapters in this book describe interventions for children and adolescents. Occupational therapists
improve children’s performance and participation (1) by providing interventions to enhance
performance; (2) by recommending activity adaptations and environmental modifications; and (3)
through consultation, coaching, and education. These intervention methods complement each other and
in best practice are applied together to support the child’s optimal growth and function. The pediatric
occupational therapist selects interventions that have established efficacy through research. Evidence-
based interventions for each area of occupational performance are described in Chapters 10 through 15.
Throughout each of the chapters that discuss intervention, a variety of essential concepts emerge.

Pediatric Occupational Therapists Focus on Inclusion

Inclusion is an issue of social justice and occupational therapists believe that children and youth with
disabilities have a right to participate in all aspects of life with their typically developing peers, in
schools and in the community (AOTA, 2014b, 2015). Therefore pediatric occupational therapists strive to
provide integrated services in natural environments (AOTA, 2015). Legal mandates such as IDEA (2005)
require that services to children with disabilities be provided in environments with children who do not
have disabilities. Services for infants and toddlers must be provided in “natural environments” and
services for preschool and school-aged children must be provided in the “least restrictive environment.”
The infant’s natural environment is most often his or her home, but it may include any place that the
family defines as the child’s natural environment. This requirement shifts when the child reaches school
age, not in its intent but with recognition that community schools and regular education classrooms are
the most natural and least restrictive environments for services to children with disabilities. Integrated
therapy in the schools ensures that the occupational therapist’s focus is situated within the classroom
curriculum and the occupational therapist’s presence in the classroom benefits the instructional staff,
who observe the occupational therapy intervention. Integrated services therefore increase the likelihood
that adaptations and therapeutic techniques will be carried over into classroom activities.

32
Table 1.3

Guiding Questions to Ask About Contextual Features

Area Question
Physical space and layout
Community Mobility and
Transportation
Materials and supplies
Safety
Social / A itudinal
Is the child’s home and classroom layed out in a way that allows mobility throughout the
space?
In the school, are the things the child needs within the child’s reach from the child’s level?
Are there obstacles such as stairs without ramps, heavy doors without electric aide to open?
Is the playground accessible and does it provide options for children with physical or
intellectual disability?
Is the environment excessively stimulating (noise, visual stimuli, movement of peers)?
Are there quiet or subdued spaces to allow for retreat from noise and overstimulation?
Is there an appropriate place for the child to eat with peers in the same area in which they eat?
Does the child have the ability to easily leave the home and venture into the community?
(mobility device if needed, sidewalks with curb cuts)
Does the child have access to transportation in the community?
Is there appropriate parking and adequate options for access where the family would like to
go? (elevators, ramps, etc.)
Are materials to promote the child’s development and participation available?
Is there equipment available to allow the child to be with peers during varied activities (on the
floor, standing at sandbox)?
Are opportunities for exploration, play, and learning available?
Are a variety of sensory experiences available?
Is appropriate technology available to enable access to activities peers are engaged in?
Does the environment allow safe physical access?
Does the environment provide an optimal level of supervision and adult assistance?
Is the environment conducive to social interaction, and does it provide opportunities for social
interaction?
Is positive adult support available, readily accessed, and developmentally appropriate?
Are peers accepting and welcoming? Is this child included in typical activities? Are there any
indications of bullying?
Is the child encouraged and supported to take risks and a empt greater independence?

Inclusion in natural environments or regular education classrooms succeeds only when specific
supports and accommodations are provided to children with disabilities (Guralnick & Bruder, 2016).
Occupational therapists are important team members in making inclusion successful for children with
disabilities. To support inclusion of children and youth with disabilities in natural environments,
occupational therapists may recommend modifications to increase physical access, accommodations to
increase social participation, or strategies to improve the child’s ability to meet the performance and
behavioral expectations. For example, occupational therapists often have roles in evaluating physical
access in schools or jobs and recommending assistive technology or task modification. Chapter 19
explains assistive technology evaluation and intervention.
Occupational therapists need to take care in their efforts at providing interventions to foster inclusion
rather than impede it. Many small decisions made in natural environments regarding the
implementation of therapy services can create barriers and actually exclude children with disabilities
(Fallang, Øien, Østensjø, & Gulbrandsen, 2017). For example, children may be inadvertently excluded
from doing something that the rest of the class is doing, while instead working on their “therapy
program” with a paraprofessional. Occupational therapists may need to spend time observing in the
classroom to determine the types of activities that are leading to exclusion. For example, if the rest of the
class is doing an activity on the floor in prone with the teacher, a child in a wheelchair may be excluded
and instead of feeling a sense of belonging with the class, may feel alone and different while si ing
behind and above peers in the wheelchair (Fallang et al., 2017). In situations such as these, an important
aspect of therapy to improve inclusion may be the education of others.

Pediatric Occupational Therapists Use Preferred Occupations and Client-Centered

Interventions to Encourage Child Engagement
Occupational therapy enables children to participate in occupations that are meaningful to them and
allow them to engage with others. For young children, play is a primary occupation and playfulness
and creativity is an important aspect of an occupational therapy intervention (Kuhaneck, Spi er, &
Miller, 2010). A growing body of evidence documents the importance of play for learning (Whitebread
et al., 2017) but pediatric occupational therapists also value play as an occupation, because it is
meaningful for children, fun, and enhances quality of life (Shikako-Thomas et al., 2012) (see Chapter 11
for further discussion of this point). Play is just one of the childhood occupations, however, and

33
pediatric occupational therapists select interventions that target the occupations of importance to the
client.
Pediatric occupational therapy must be child-centered. In child-centered practice, children are given
choices to the extent that they are able to participate in making them. Children participate in decision
making about goals and occupational therapists use activities that are meaningful and preferred by the
child, knowing that they engage the child’s efforts. Children are more motivated to take on skill
challenges that they have designated as important and that the occupational therapist embeds in
preferred activities. The occupational therapist collaborates with the child to select an activity of
interest, makes the activity fun and playful, and gives the child choices (Kuhaneck, Spi er, & Miller,
2010).
The child’s engagement in an activity is an essential component of a therapy session. This engagement
funnels the child’s energy into the activity, helps him or her sustain full a ention, and implies that the
child has adopted a goal and purpose that fuels his performance in the activity. When children are given
supports that enable them to focus on and engage fully in a learning activity, they are more likely to
persevere and a empt challenging aspects of the activity. Generally, the intrinsic sense of mastery is a
stronger reinforcement to the child and youth with greater probability of sustained effects than external
rewards, such as verbal praise or other contingent reward systems. When children are motivated to
participate and share positive affect and the experience with others involved in an activity, they will
more readily sustain engagement with that activity and thereby promote their learning (Froiland, &
Oros, 2014; Gopalan et al., 2017; Kindermann, 2007; Master, Cheryan, & Mel off, 2017 ). Activities
without social features or those that provide additional extrinsic motivation may not capture and
sustain engagement for as long and may not improve learning outcomes (McKernan et al., 2015;
Ronimus, Kujala, Tolvanen, & Lyytinen, 2014). Key features of sensory integration intervention (Parham
et al, 2011) include soliciting the child’s active engagement and tapping the child’s inner drive.
Engagement is essential because the child’s brain responds differently and learns more effectively when
he or she is actively involved in a task rather than merely receiving passive stimulation (see Chapter 20
for more information about inner drive).
The Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Rodger &
Polatajko, 2017)(see Chapter 17 for a more thorough description of this approach) also promotes the
child’s intrinsic motivation and engagement through the use of a performance goal of interest to the
child and chosen by the child. CO-OP is a task-oriented, problem-solving approach that engages the
child or youth in se ing goals and planning strategies to improve performance. By guiding the child to
identify the performance problem and then se ing a feasible goal and plan for reaching that goal, the
occupational therapist encourages the child’s own problem-solving and investment in achieving that
goal. Engaging the child as a collaborator in the intervention process enhances the child’s motivation,
best efforts to improve performance, and sustained engagement. This approach has been used
effectively with a variety of children with different diagnoses.
The use of occupation-centered approaches for children are supported by research ( Pfeiffer, Clark, &
Arbesman, 2018; Kreider et al., 2014; Rodger & Polatajko, 2017 ) and by theories of motor control and
motor learning (Cano-De-La-Cuerda et al., 2015). Whole activities with multiple steps and a meaningful
goal (versus repetition of activity components) elicit the child’s full engagement and participation.
Repeating a single component (e.g., squeeze the Play-Doh or place pennies in a can) has minimal
therapeutic value. By engaging in an activity with a meaningful goal (e.g., cooking or an art project),
children use multiple systems and organize their performance around that goal. For example, if a game
requires that a preschool child a end to a peer, wait for his turn, and correctly place a game piece, the
child is developing the joint a ention that he needs to participate in circle time or a family meal. Motor
learning approaches use such task-oriented interventions, acknowledge the importance of engaging
children in meaningful, purposeful activities to harness their motivation and full efforts (see Chapter
16).

Pediatric Occupational Therapists Modify and Adapt Activities to Create the “Just-
Right Challenge”
A child’s active participation and efforts to achieve a task are elicited when therapeutic activities are at
just the right level of complexity; that is, where the child not only feels comfortable and nonthreatened
but also experiences some challenge that requires effort. An activity that is a child’s just-right challenge
has the following elements: the activity (1) matches the child’s developmental skills and interests; (2)
provides a reasonable challenge to current performance level; (3) engages and motivates the child; and
(4) can be mastered with the child’s focused effort.

34
 Based on careful analysis of performance and behavior, the occupational therapist selects an activity
that matches the child’s strengths and limitations across performance domains. The analysis allows the
occupational therapist to individualize the difficulty, pace, and supports needed for a child to
accomplish a task. The occupational therapist vigilantly a ends to the child’s performance during an
activity to provide precise levels of support that enable the child to succeed. Cognitive, sensory, motor,
perceptual, or social aspects of the activity may be made easier or more difficult (see Case 1.2). By
precisely assessing the adequacy of the child’s response, the occupational therapist finds the just-right
challenge. A child’s self-esteem and self-image are influenced by skill achievement and by success and
task mastery. Self-determination is described throughout the book.

Case 1.2Grading an Activity: Challenging and Eliciting Full

Participation
Aaron, a 10-year-old boy with autism, participated in a cooking activity with the occupational therapist
and three peers. The children were proceeding in an organized manner—sharing cooking supplies and
verbalizing each step of the activity. As they proceeded, Aaron had great difficulty participating in the
task; the materials were messy, and the social interaction was frequent and unpredictable. He
performed best when the activity was highly structured, the instructions were very clear, and the social
interaction was kept at a minimum. To help him participate at a comfortable level, the occupational
therapist suggested that his contribution to the activity be to put away supplies and retrieve new ones.
The other children were asked to give him specific visual and verbal instructions as to what they
needed and what should be replaced in the refrigerator or cupboard. With this new rule in place, the
children gave simple and concrete instructions that Aaron could follow. An important element of this
strategy was that it included the support of his peers to elicit an optimal level of participation and could
be generalized to other small-group activities involving Aaron and his peers.

Although the occupational therapist often presents challenges and asks the child to take risks, the
therapist supports and facilitates the child’s performance so that either the child succeeds, or feels okay
when he or she does not. By choosing activities that allow the child to feel important and by grading the
activity to match the child’s abilities, the occupational therapist gives the child the opportunity to
achieve mastery and a sense of accomplishment.The therapist is invested in the child’s success, and
reinforces the importance of the child’s efforts. Concepts of mastery, self-efficacy, and self-determination
are illustrated in many chapters.

Pediatric Occupational Therapists Modify and Adapt Environments and Tasks to

Enable Access and Participation
To succeed in a specific se ing, a child with disabilities often benefits from modifications to the
environment. Goals include not only enhancing a child’s participation but also increasing safety (e.g.,
reducing barriers on the playground) and improving comfort (e.g., improving ease of wheelchair use by
reducing the incline of the ramp). Children with physical disabilities may require specific environmental
adaptations to increase accessibility or safety. For example, although a school’s bathroom may be
accessible to a child in a wheelchair, the occupational therapist may recommend the installation of a
handlebar beside the toilet so that the child can safely perform a standing pivot transfer. Desks and table
heights may need to be adjusted for a child in a wheelchair.
Environmental adaptations, such as modifying a classroom or a home space to accommodate a
specific child with a disability, can be accomplished only through partnership with the adults who
manage the environment. High levels of collaboration are needed to create optimal environments for the
child to a end and learn at school and at home. Environmental modifications often affect everyone in
that space, so the modifications must be appropriate for all children in that environment. The
occupational therapist articulates the rationale for the modification and negotiates the changes to be
made by considering what is most appropriate for all, including the teacher and other students.
Through discussion, the occupational therapist and teacher reach agreement as to what the problems
are regarding the environment. With consensus regarding the problems and desired outcomes, often the
needed environmental modification logically follows. It is essential that the occupational therapist
follow through by evaluating the impact of the modification on the targeted child and others. The
Americans with Disabilities Act provides guidelines for improving accessibility to schools and
community facilities.

35
 Occupational therapists often help children with disabilities participate by applying assistive
technology. Technology is pervasive throughout society, and its increasing versatility makes it easily
adaptable to an individual child’s needs. Technology is often divided into low-tech and high-tech
options.
Low-technology solutions are often applied to increase the child’s participation in activities of daily
living. Examples include built-up handles on utensils, weighted cups, elastic shoelaces, and electric
toothbrushes. Adapted techniques can be used to increase independence and reduce caregiver
assistance in eating, dressing, or bathing. Low-technology solutions can also be used to support
participation in play activities. Adapted techniques for play activities may include switch toys, ba ery-
powered toys, enlarged handles on puzzle pieces, or magnetic pieces that can easily fit together.
High-technology solutions are often used to increase mobility or functional communication. Examples
are power wheelchairs, augmentative communication devices, and computers. Occupational therapists
frequently support the use of assistive technology by identifying the most appropriate device or system
and features of the system. They often help families obtain funding to purchase the device, set up or
program the system, train others to use it, and monitor its use. Occupational therapists also make
themselves available to problem-solve the inevitable technology issues that arise.
In many school systems, the occupational therapist serves as an assistive technology consultant or
becomes a member of a district-wide assistive technology team. Assistive technology teams have been
formed to provide support and expertise to school staff members in applying assistive technology with
students. These teams make recommendations to administrators on equipment to order, train students
to use computers and devices, troubleshoot technology failures, determine technology needs, and
provide ongoing education to staff and families. Use of assistive technology is particularly helpful to
adolescents preparing for supported employment. The role of the pediatric occupational therapist with
high-tech devices is further explored in Chapters 18 and 19. Low-tech options are discussed in Chapters
12, 15, 19, and 25.
Often a role of the occupational therapist is to recommend adaptations to the sensory environment
that accommodate children with sensory processing problems in the home or at school ( Dunn, Cox,
Foster, Mische-Lawson, & Tanquary, 2012; Kuhaneck & Kelleher, 2018). Preschool and elementary
school classrooms usually have high levels of auditory and visual input (Kuhaneck & Kelleher, 2015).
Classrooms with high noise levels may be overwhelmingly disorganizing to a child who is
hypersensitive to auditory stimulation. Young children who need calming techniques or quiet times
during the day may need their own physical space in the corner of the room where they are allowed to
“take a break” intermi ently throughout the school day. The occupational therapist may suggest that a
preschool teacher implement a quiet time with lights off to provide a period to calm children. Other
environmental modifications may improve arousal and a ention in children such as si ing on movable
surfaces. Modifications should enhance the child’s performance; make life easier for the parent or
teachers; and have a neutral or positive effect on siblings, peers, and others in the environment. Owing
to the dynamic nature of the child and the environment, adaptations to the environment may require
ongoing assessment to evaluate the goodness-of-fit between the child and the modified environment
and determine when adjustments need to be made. Contextual modifications to accommodate a child
who has sensory processing problems are described in multiple chapters including 15, 20, 24, and 30. A
recent review of these approaches (Bodison & Parham, 2018) suggests that certain techniques may be
effective while others are not. See Chapter 20 for a more detailed discussion of this evidence.

Pediatric Occupational Therapists Use Interventions That Are Documented to Be

Effective
With extensive availability of research on pediatric practice, competent practitioners read, appraise, and
use this evidence when making clinical decisions about intervention. However, despite wide agreement
among professionals regarding the importance of evidence-based practice (EBP), studies have shown that
research findings are not routinely integrated into everyday practice (Greenhalgh, Howick, & Maskrey,
2014; Upton, Stephens, Williams, & Scurlock-Evans, 2014). Barriers to implementing research findings
fully into daily practice include occupational therapists’ limited time to read and consume all the
available evidence and lack of administrative support to develop systems for routinely using evidence
in practice.
With the proliferation of published research related to pediatric occupational therapy, organizations,
including the AOTA, have supported the development of EBP guidelines (see
h ps://www.aota.org/Practice/Researchers/practice-guidelines.aspx). EBP guidelines are developed by a
group of experts who synthesize the research on a particular intervention or diagnosis to formulate

36
recommendations for practice. These guidelines translate the research evidence to practice by making
specific recommendations for evaluations and interventions that prioritize the recommendations using a
grading system.
Hospitals and medical systems have promoted the use of EBP guidelines to improve the consistency
and effectiveness of medical interventions (Kredo et al., 2016). Schools and educational systems have
also called for research evidence to be used to guide educational practices and policies (Russo-Campisi,
2017). Clinical guidelines enable efficient consumption of efficacy research; however, implementing the
guidelines consistently also requires commitment, system and environmental supports, and consensus
among the agency’s or program’s team. EBP clinical guidelines have been adopted by children’s
hospitals and medical systems as tools to promote quality improvement and patient outcomes
(Cincinnati Children’s Evidence-Based Care Recommendations, n.d.). When EBP guidelines are
implemented within quality improvement processes, they also are embedded in existing processes that
include monitoring and examining outcomes. Numerous steps are needed to ensure that use of EBP
guidelines results in improved outcomes (Box 1.1).
Case 1.3 describes using an EBP guideline in clinical decision making for a young child with autism
spectrum disorder.
There are benefits to using the recommendations from EBP guidelines; they:

1. Are relevant because experts in the diagnosis or type of intervention determine the scope and
methods for developing the recommendations.

Box 1.1 Steps in Evidence-Based Practice

Step 1
• Convert the need for information (about intervention effects, prognosis, therapy
methods) into an answerable question.
Step 2
• Search the research databases using the terms in the research question.
• Track down the best evidence to answer that question.
Step 3
• Critically appraise the evidence for its:
• validity (truthfulness)
• impact (level of effect)
• clinical meaningfulness
Step 4
• Critically appraise the evidence for its applicability and usefulness to your practice.
Step 5
• Implement the practice or apply the information.
• Evaluate the process.

2. Represent synthesis of current research that is appraised and evaluated.

3. Incorporate appraisal of available evidence by grading the recommendations based on the rigor
of the research; these grades determine the importance and priority of the recommendations.
4. Represent the consensus of the experts.

Following clinical guidelines has the potential of increasing the consistency of practice and its efficacy.
The likelihood of positive outcomes is high when occupational therapists (1) select EBP guidelines with
optimal fit to their clientele and environment; (2) adapt the guidelines to fit their work environment; (3)
modify them into user-friendly protocols; (4) examine and resolve barriers to implementation; and (5)
establish systems to monitor their outcomes (Carey, Buchan, & Sanson-Fisher, 2009). All of the chapters
in this book use research evidence in describing evaluation and intervention.

Pediatric Occupational Therapists Educate and Advocate for Others and Engage in
Competent Interprofessional Practice
Pediatric occupational therapy involves working intimately with caregivers and teachers to create
opportunities for the child to participate optimally across environments. This aspect of service delivery
is challenging and fulfilling because it requires a complementary skill set to assess, plan, implement,
and evaluate the effects of parent and teacher consultation, coaching, and education.

37
Consultation and Coaching
Services “on behalf of” children complement and extend direct service delivery. Occupational therapists
provide these indirect services by consulting with, coaching, and educating parents, assistants, childcare
providers, and any adults who spend a significant amount of time with the child. Through these models
of service delivery, the occupational therapist helps develop solutions that fit into the child’s natural
environment and promotes the child’s transfer of new skills into various environments.
A major role for school-based occupational therapists is to support teachers in providing optimal
instruction to students and helping children succeed in school (Hanft, Shepherd, & Read, 2013) (see
Chapters 15 and 24). Occupational therapists accomplish this role by promoting the teacher’s
understanding of the physiologic and health-related issues that affect the child’s behavior and helping
teachers apply strategies to promote the child’s school-related performance. Occupational therapists
also support teachers in adapting instructional activities that enable the child’s participation and
collaborate with teachers to collect data on the child’s performance. This focus suggests that, in the role
of consultant, the occupational therapist sees the teacher’s needs as a priority and focuses on supporting
his or her effectiveness in the classroom. Consultation is most likely to be effective when occupational
therapists understand the curriculum, academic expectations, and classroom environment.

Case 1.3 Using Evidence-Based Practice Guidelines for Restricted Eating

in Autism Spectrum Disorder
Background
Meg, a school-based occupational therapist, initiated intervention for Rebecca, a 5-year-old girl with
autism with highly restricted eating. Meg evaluated Rebecca and determined that she eats eight to nine
foods throughout the day as snacks. She does not participate in mealtime with the family because she
has a tantrum when foods that are not part of her diet are presented. Rebecca eats crackers, cereals,
chips, noodles, and French fries, and she occasionally eats yogurt, milk, and cheese. She interacts with
her caregiver using gestures and two-word sentences. She also uses jargon that does not have
communicative intent. She is very skilled in computer tablet games, puzzles, and Lego blocks. She is
independent in eating and dressing but continues to require some assistance with bathing, and she
dislikes water and soap. Rebecca’s parents have prioritized her eating as a first occupational therapy
goal.
Meg accessed the BESt evidence statement from Behavioral and Oral Motor Interventions for Feeding
Problems in Children (Cincinnati Children’s Hospital and Medical Center, 2013) to guide her intervention
planning. Listed in order of evidence strength, the following BESt recommendations seemed relevant,
appropriate given Rebecca’s age and behaviors, and feasible to implement at home and school. These
recommendations were particularly applicable because Rebecca exhibited significant behavioral rigidity
and stereotypic behaviors, and she did not appear to have sensory processing problems.

• It is recommended that the following behavioral interventions within a treatment package may be
used to increase intake for children with feeding problems:
• Differential a ention
• Positive reinforcement
• Escape extinction/escape prevention
• Stimulus fading
• Simultaneous presentation

It is recommended that a child (4 months to 7 years old) with feeding difficulties be exposed 10 to 15
times to a previously unfamiliar or nonpreferred food to increase intake (Cincinnati Children’s Hospital
Medical Center, 2013).
An intervention was designed in which a nonpreferred food was placed on Rebecca’s plate with her
preferred foods twice a day. The teacher or occupational therapist implemented the intervention at
school, and the mother implemented it once each day at home. The occupational therapist, teacher, or
parent gave Rebecca praise and a ention when she touched, played with, or tasted the nonpreferred
foods. The occupational therapist and parent ate some of the nonpreferred hamfood with her, modeling
for her and having fun with that food. The same nonpreferred food was presented at least 10 times. The
occupational therapist and parent used highly positive affect during the meal, and although Rebecca

38
was allowed to eat her preferred foods, she was praised and reinforced only when she ate a
nonpreferred food. The table was arranged to make escape very difficult, and she was encouraged to
stay at the table.
In the first week, Rebecca did not eat any nonpreferred foods, but she touched and played with these
foods (fruits, cream cheese, peanut bu er, and pita bread). In the second week, she took several bites of
nonpreferred foods each week, and by the third week, her regular diet had increased to 11 foods,
including fruit, cream cheese, and peanut bu er. Meg, the teacher, and Rebecca’s mother recorded and
tracked her eating and mealtime behavior each day to decide which foods to try and which
reinforcement seemed most effective.
Summary
This guideline on feeding problems effectively improved Rebecca’s eating and diet because:

• Rebecca’s mother and teacher were invested in implementing mealtime interventions.

• The occupational therapist created a protocol from the feeding guideline that worked both at home
and at school.
• The occupational therapist, teacher, and mother were commi ed to implementing the protocol
consistently.
• A system for routinely assessing Rebecca’s intake and behavior was developed and implemented.

Adapted from Cincinnati Children’s Hospital Medical Center (2013). Best evidence statement (BESt). Behavioral
and oral motor intervention for feeding problems in children. h p://www.guideline.gov/content.aspx?
id=47062&search=autism%2c+eating. Accessed March 10, 2014.

Effective consultation also requires that the teacher or caregiver be able to assimilate and adapt the
strategies offered by the occupational therapist and make them work in the classroom or the home. The
occupational therapist asks the teacher how he or she learns best and accommodates that learning style.
Teachers need to be comfortable with suggested interventions, and occupational therapists should offer
strategies that fit easily in the classroom routine. The occupational therapist and teacher can work
together to determine which interventions would benefit the child and be least intrusive to other
students.
Specific methods of coaching, such as occupational performance coaching (OPC), allow an
occupational therapist to collaborate with a parent or teacher. Coaching methods aim to empower
parents and enable their success, and increase their feelings of competence and efficacy. Studies to date
on coaching methods with parents have been positive ( Dunn, Cox, Foster, Mische-Lawson, & Tanquary,
2012; Foster et al., 2013; Graham, Rodger, & Ziviani, 2014; 2013; Graham et al., 2010; Graham, Rodger, &
Ziviani, 2013). One model based on collaborative coaching has been successfully implemented with
teachers for students with developmental coordination disorder (DCD) (Dancza, Missiuna, & Pollock,
2017; Missiuna et al., 2012).

Education and Advocacy

Occupational therapists also educate administrators and policymakers about the need to improve
accessibility of recreational, school, or community activities. They work directly with school curriculum
commi ees to modify curriculum materials and develop educational materials that align with the core
curriculum and use universal design. They educate the public to improve a itudes toward disabilities.
By participating in curriculum revision or course material selection, occupational therapists can help
establish a curriculum that meets required standards but has sufficient flexibility to meet the needs of
children and youth with disabilities. Often a system problem that negatively affects one child is
problematic to others as well. The occupational therapist needs to recognize which system problems can
be changed and how these changes can be encouraged. For example, if a child has difficulty reading and
writing in the morning, he or she may benefit from physical activity before a empting to focus on
deskwork. The occupational therapist cannot change the daily schedule and move recess or physical
education to the beginning of the day, but he or she may convince the teacher to begin the first period of
the day with warm-up activities. The occupational therapist can educate teachers on the benefits of
using a simplified, continuous stroke handwriting curriculum, which can benefit children with motor-
planning problems but also benefit all children beginning to write. Education on accessible playgrounds
can promote greater participation and safety on the playground for all children, regardless of skill
levels. Education and advocacy regarding the impact of play materials on the playground may promote

39
changes allowing greater physical activity levels (Engelen et al., 2013) which are recommended to aid in
the reduction of childhood obesity (CDC, 2018) and perhaps improve performance in school (Singh
et al., 2018)
Occupational therapists advocate for environments that are both physically accessible and welcoming
to children with disabilities. With an extensive background on which elements create a supportive
environment, occupational therapists can help design physical and social environments that facilitate
the participation of every child. To change the system on behalf of all children, including children with
disabilities, requires communication with stakeholders or persons who are invested in the change. The
occupational therapist needs to share confidently the rationale for change, appreciate the views of others
invested in the system, and change and negotiate when needed.
A system change through education is most accepted when the benefits appear high and the costs are
low. Can all children benefit? Which children are affected? If administrators and teachers in a childcare
center are reluctant to enroll an infant with a disability, the occupational therapist can advocate for
accepting the child by explaining specifically the care that the child would need, the resources available,
the behaviors and issues to expect, and the benefits to other families.
Convincing a school to build an accessible playground or establish a completely accessible computer
lab are examples of how a focused education effort can create system change. Occupational therapists
are frequently involved in designing playgrounds that are accessible to all and promote the
development of sensory motor skills. Another example is helping school administrators select computer
programs that are accessible to children with disabilities. The occupational therapist can serve on the
school commi ee that selects computer software for the curriculum and advocate for software that is
easily adaptable for children with physical or sensory disabilities. A third example is helping
administrators and teachers select a handwriting curriculum to be used by regular and special
education students. The occupational therapist may advocate for classroom instruction that emphasizes
prewriting skills or one that takes a multisensory approach to teaching handwriting. The occupational
therapist may also advocate for adding sensory-motor-perceptual activities to an early childhood
curriculum.

Interprofessional Teamwork
Most occupational therapists work on teams with other professionals. In pediatric practice, the team
members always include the parent(s) or primary caregiver(s), as well as other professionals such as
speech language pathologists, physical therapists, teachers, social workers, doctors, nurses, and
psychologists. Although professions have been characterized in the past as having vast differences
related to the process of professionalization, they actually share many of the same values (Grace et al.,
2017). Two of these include valuing client’s rights and valuing the capacity of one’s particular profession
to provide needed care to clients. Authors have recently conceptualized interprofessional practice
therefore as an intersection between the client’s right to receive healthcare that is the best that is
currently available, and the recognition of contributions of each of the individual professions involved
in that care (Grace et al., 2017). This type of model challenges the paradigm distinguishing professions
based on scope of practice.
Although to date, the evidence related to the impact on healthcare outcomes of interprofessional
practice is inconclusive, there has been an explosion of research as well as a huge growth in programs to
institute interprofessional practice in healthcare and interprofessional education in healthcare education
(Reeves et al., 2017). In recent years, the greater focus on interprofessional practice has led to a variety of
initiatives to be er educate students in healthcare and improve the interprofessional skills of current
practitioners using methods of be er teamwork and specific teaming competencies (Muhlenhaupt,
Pizur-Barnekow, Sche ind, Chandler, & Harvison, 2015). The Interprofessional Education
Collaborative Expert Panel (2011) has identified four core competency domains of interprofessional
practice. These include (1) working with professionals in a climate of mutual respect and shared values;
(2) using knowledge of each team members role to manage the healthcare needs of clients served; (3)
communicating with clients and other professionals in a manner that supports a team approach; and (4)
applying principles of group dynamics to perform effectively in varied roles to provide safe, effective,
and equitable care. Working in teams requires a shared identity, a clear role, task, and or goals,
interdependence of team members, integration of teamwork, and a shared responsibility (Reeves,
Xyrichis, & Zwarenstein, 2018). However, teamwork is just one way in which to work
interprofessionally. Team members also must engage in collaboration, coordination, and networking,
and each of these focuses differently on the varied requirements of teamwork (Reeves, Xyrichis, &
Zwarenstein, 2018; Xyrichis, Reeves, & Zwarenstein, 2018).

40
 Networking is the most different form of “teamwork.” In a hospital or acute care se ing, the care
network for one client can be massive and complex, thus making face to face collaboration almost
impossible (Dow et al., 2017). In these type of interprofessional networks the members may not meet
face-to-face, but may communicate via email or online conferencing. Interprofessional networks vary
over time and different professionals enter and leave at varied times, often unpredictably. Much of the
work on teams that has been the basis of interprofessional practice is based in teams that are smaller,
and more fixed, such as in business. However this work may have limited usefulness in certain arenas of
healthcare where networking may be more important.
The literature on interprofessional practice and healthcare suggests that for new practitioners entering
pediatric practice, it is critical that the practitioner understand his or her practice se ing and the value
and importance of both teams and networks in that se ing. Although healthcare practitioners may value
interprofessional practice (Bode, Giesler, Heinzmann, Krueger, & Straub, 2016), they often lack training
in it. Therefore the practitioner must learn to be competent with the skills that are appropriate for
interprofessional practice in that particular se ing. Further information regarding working with teams
is provided in Chapter 3.

Pediatric Occupational Therapists Plan Interventions to Generalize Across

Environments
Occupational therapists carefully plan strategies for children to generalize newly learned skills.
Recognizing that transfer of new skills to natural environments does not always automatically follow
performance of that skill in an intervention session; occupational therapists plan multiple ways for
children to practice new skills in various tasks. They also recommend supports for performance that will
ensure success. To support the generalization of new skills, occupational therapists educate caregivers
and teachers to support and reinforce that practice. They suggest strategies to support the child’s
practice of skills in a variety of tasks.
Many research-based interventions include specific components to help the child generalize newly
learned skills. Often these are home programs carefully developed in collaboration with parents to
ensure that they are a good fit. Novak (2011) describes the components of an effective home program.
She defines a “partnership home program” as one that includes (1) establishing a collaborative
partnership between the parent, child, and occupational therapist; (2) establishing parent and child
goals; (3) selecting therapeutic activities that focus on achieving family goals; (4) supporting parents to
implement the program through education, home visiting, and progress updates; and (5) evaluating
outcomes. These elements are important to promoting the child’s ability to generalize emerging skills to
home activities. Approaching home programs first as a partnership, checking progress, and supporting
parents throughout, has demonstrated efficacy for improving parent efficacy and the child’s function
(Novak & Berry, 2014).

Pediatric Occupational Therapists Use Varied Models of Service Delivery

There are a variety of possible service delivery models and methods for pediatric occupational therapy
(AOTA, 2014a). In direct service provision, the child is seen by the therapist either individually or in a
group. In consultation models, the child receives indirect service through the occupational therapist’s
collaboration and communication with another professional, such as a teacher. Additional indirect
services include advocating on behalf of the client. Telehealth is an emerging model of service delivery
with promise to alleviate difficulties related to personnel shortages, regional differences in access to
therapists, and wait times (Cason, 2014). Telehealth models are indirect service provision, often
provided through collaboration, consultation, or coaching. Service delivery choices often vary by
practice se ing. (See Chapters 22, 23, 24, 25, 26, and 27 for consideration of how the se ing impacts
service delivery).
In school-based practice, the terms push in and pull out are also used to describe service delivery
(Clough, 2018). Pull out service delivery is used when a therapist removes a child from the classroom to
work on direct interventions focused on specific skill development. Push in models are used in the
classroom, when a therapist works side by side directly with a student on either the classroom activity
at that time, or another therapeutic activity the therapist has brought in. In multitiered service delivery
models for education, services and supports are given in levels based on intensity (Giangreco & Suter,
2015). Newer models of service delivery in the schools require that pediatric occupational therapists
focus on their total workload, as opposed to the number of children on their caseload (Garfinkel &
Seruya, 2018). Workload includes both direct and indirect service delivery. In the 3:1 model, therapists

41
provide direct intervention 3 weeks per month and have 1 week per month for indirect services
(Garfinkel & Seruya, 2018).
There is limited research to guide occupational therapists’ decision making related to direct versus
indirect interventions, and much of it is old (Davies & Gavin, 1994; Dunn, 1990; Dreiling & Bundy, 2003;
Kingsley & Mailloux, 2013). However, in the early studies and more recent ones, few, if any, differences
were found in effectiveness between direct and consultative services. Occupational therapists continue
to use and often prefer more traditional models of practice (Clough, 2018). Occupational therapists may
tend to choose the model of service delivery based on their planned interventions and the schedule of
the classroom activities and these decisions may be made based on the child’s age or grade level
(Clough, 2018).
Recent research does suggests that collaborative, inclusive interventions are the most effective (Anaby
et al., 2018) indicating that indirect and push in models would be best. Occupational therapists who
have made the change to a workload model such as the 3”1 model may feel be er equipped to provide
indirect services and manage their time to be er intervene in natural environments (Garfinkel & Seruya,
2018). Other models for school-based service delivery that offer the possibility for greater flexibility
(Case-Smith & Holland, 2009) include block scheduling and co-teaching. These models of flexible
scheduling allow occupational therapists to move fluidly between direct and consultative services.
In block scheduling, occupational therapists spend 2 to 3 hours in the early childhood classroom
working with children with special needs one on one and in small groups, while supporting the
teaching staff. Block scheduling allows occupational therapists to learn about the classroom, develop
relationships with the teachers, and understand the curriculum so that they can design interventions
that are easily integrated into the classroom. By being present in the classroom for an entire morning or
afternoon, the occupational therapist can find natural learning opportunities to work on a specific
child’s goals. During the blocked time, the occupational therapist can run small groups, collaborate with
the teacher and assistants, evaluate the child’s performance, and monitor the child’s participation in
classroom activities.
Another integrated model of service delivery is co-teaching (Solis, Vaughn, Swanson, & Mcculley,
2012). In this model, the occupational therapist and teacher plan and implement the sessions together.
Collaborative planning allows interdisciplinary perspectives on student issues and behaviors; enables
the occupational therapist to align interventions closely with the curriculum; and ensures that
interventions can be feasibly implemented in the classroom, with consideration given to the teacher’s
goals and curricular expectations. Co-teaching models have been successfully implemented for
handwriting programs, in which occupational therapists take on teaching roles while providing
individualized supports and interventions for students who have handwriting difficulties (Case-Smith,
Holland, & White, 2014). Benefits of co-teaching are that occupational therapy services are embedded
into the classroom instruction; students at risk receive more intensive instruction with individualized
supports; and students with individualized education programs receive integrated services that support
performance throughout their school day.
In a fluid service delivery model, therapy services increase when naturally occurring events create a
need—for example, when the child obtains a new adapted device, when the child has surgery or casting,
or when a new baby brother creates added stress for a family. Similarly, therapy services should be
reduced when the child has learned new skills that primarily need to be repeated and practiced in his or
her daily routine or the child has reached a plateau on therapy-related goals.

Pediatric Practice: Similarities and Differences to Adult

Practice
Occupational therapy with pediatric clients is both similar to and different from other areas of
occupational therapy. In many ways, pediatric practice is just like practice with adults or the elderly.
Pediatric occupational therapists share the same philosophy, engage in the same processes, and possess
the same overall belief system in relation to human beings as occupational therapists in other se ings.
All occupational therapists must work with and manage interactions with family members, whether the
family members are spouses, siblings, children, parents, or grandparents.
What often makes pediatric practice unique is the influence of certain US policies related to specific
se ings that pediatric practitioners work in, such as the public schools. The laws that apply to practice
with school age children, and the law that applies to early intervention with infants to children 3 years
of age, are different than the laws that influence practice with adult clients. The laws often place

42
different boundaries around occupational therapy practice by specifying the role of the occupational
therapist within that policy’s implementation.
Additionally, these unique practice se ings influence the structure of the teams with whom pediatric
occupational therapists work. Although most occupational therapists work with some sort of care team,
the people on the team vary by se ing. Since the large majority of pediatric occupational therapists
work in the public schools, they collaborate with teachers and school psychologists rather than with
doctors or nurses.
Funding issues for occupational therapy for minor children may also be different than those of
working or unemployed adults or the elderly who have Medicare. For example, over 9 million children
received funding for their healthcare through the Children’s Health Insurance Program (CHIP) (Centers
for Medicaid and Medicare Services, 2018). Children may also receive funding for occupational therapy
from Medicaid, or from employer sponsored insurance. Under Medicaid, occupational therapy is an
optional program that is decided on a state by state basis. For adults, 36 states provide coverage for
occupational therapy (Kaiser Family Foundation, 2018). However, coverage for occupational therapy for
children varies from 67% of states providing some coverage for occupational therapy services to 100% of
states providing some coverage, based on the way in which funding is provided (i.e., by employer-
based insurance or by CHIP either as a Medicaid extension or a separate program). Recent health care
changes may impact funding for services provided to children (AOTA, 2018b).
Although all occupational therapists consider the life stage of their clients, the rapid changes in child
development that occur during early childhood create an additional facet for managing pediatric
assessment and intervention. Similarly, although all occupational therapists need to consider the client’s
family members and their reaction to a client’s disability, pediatric practitioners may also have to
consider the stage of development the family is in, and the way in which the parents or primary
caregivers are dealing with the initial diagnosis of their child (Seligman & Darling, 2007).
In pediatric practice, occupational therapists must balance and navigate conflicts between the
occupational needs and desires of their clients who are minors with those of their parents and other
adults who influence them and may a empt to exercise control of their access to specific occupations.
Occupational therapists may also need to navigate the differences in opinion regarding a child’s
capabilities, as parents and children do not always agree on their individual assessment of the child’s
ability level (Hemmingsson, Ólafsdó ir, & Egilson, 2017). Pediatric occupational therapists may also
have to be good detectives to uncover a child’s preferred or favored occupations, as very young or
language impaired pediatric clients may be less able to communicate their desires and contribute fully
to decisions regarding their intervention plan.
The balance of engagement in varied occupations shifts and changes across the lifespan. In pediatric
practice, especially with children as opposed to youth, the occupational therapist may find him or
herself more frequently concerned with play and education rather than work, for example. Working on
co-occupations may also be very common in certain aspects of pediatric occupational therapy, where the
client, for example an infant, may require the assistance of a caregiver to engage in occupations such as
feeding.
Lastly, the ability of a child to say, “No” is legendary and child noncompliance can occur in reaction
to an adult’s behavior or language choice (Crockenberg & Litman, 1990; Pesch et al., 2018). Compliance
with activity can similarly be influenced by adult behavior, affect, a ention, engagement, and language
use (Kochanska & Aksan, 1995). Zaidman-Zait, Marshall, Young, & Her man, 2014). In pediatric
practice, the occupational therapist may need to be quite playful and creative, as well as immersed in
the activity with the child, to gain the child’s active engagement in therapeutic activities (Kuhaneck,
Spi er, & Miller, 2010; Singer, 2013). The occupational therapist will also need to understand how to
communicate with children and youth at an appropriate level for their development (PBS, 2018; Traub,
2016).

Summary
This chapter introduces many of the essential concepts that characterize occupational therapy with
children. The occupational therapy process was briefly explained and is illustrated in depth in the
subsequent chapters of the book. Occupational therapy practice with children has matured in recent
decades from a profession that relied on basic theories and practice models to drive decision making to
one that uses scientific evidence in clinical reasoning. All chapters of this book emphasize evidence-
based interventions for children and youth across practice se ings. The subsequent chapters expand on
the basic concepts presented in this chapter by exploring the breadth of occupational therapy for

43
children, explaining theories that guide practice, illustrating practice models in educational and medical
systems, and describing interventions with evidence of effectiveness. Case examples are provided
throughout the text to allow readers to visualize occupational therapy practice with children and
adolescents. The chapter authors have provided summaries of current research in research notes and
evidence-based tables.

Summary Points
• Occupational therapists provide child-centered services to ensure that interventions are
developmentally appropriate, meaningful and motivating to the child, and well aligned
with the child’s goals.
• In family-centered services, occupational therapists develop positive relationships with
families, demonstrate compassion, exhibit responsiveness and sensitivity, and
fosterparental self-efficacy.
• Culturally competent occupational therapists respect the child and family’s culture and
design services that demonstrate respect for the family’s culture.
• Occupational therapists use top-down assessment with performance analysis to determine
how context, task demands, and performance strengths and limitations influence
theparticipation of the child or adolescent.
• Occupational therapists access, interpret, and use evidence to make clinical decisions;
high-quality, efficacious intervention uses EBP guidelines.
• Occupation-centered models include establishing a therapeutic relationship, using
occupation as a means and an end, providing a just-right challenge, providing appropriate
supports for and reinforcement of performance, and supporting generalization ofnewly
learned skills to natural environments.
• Occupational therapists advocate for inclusion and recognize the value of services
withinthe child’s natural environments.
• Environmental modifications increase the participation of the child or adolescent
inactivities for daily living, play, school functions, and work.
• Collaborative models of services delivery, such as classroom-embedded services or co-
teaching, allow occupational therapy services to be integrated into the child’s goals
forparticipating in the curriculum and functioning in the school environment.
• Occupational therapists have important roles in consulting with, coaching, and
educatingcaregivers, teachers, and other professionals who support the participation
ofchildren and adolescents with disabilities.

References
American Occupational Therapy Association. Why and How Often Do OT Practitioners Leave
Jobs? 2018. h ps://www.aota.org/Education-Careers/Advance-Career/Salary-Workforce-Survey/why-OT-
OTA-leave-jobs.aspx.
American Occupational Therapy Association. Children and
Youth. 2018. h ps://www.aota.org/Practice/Children-Youth.aspx.
American Occupational Therapy Association, . Guidelines for occupational therapy services in early
intervention and schools. American Journal of Occupational Therapy . 2017;71 doi: 10.5014/ajot.2017.716S01.
American Occupational Therapy Association, . Inclusion of children with
disabilities. 2015. h ps://www.aota.org/∼/media/Corporate/Files/Practice/Children/Inclusion-of-Children-
With-Disabilities-20150128.PDF.
American Occupational Therapy Association, . Occupational therapy practice framework: Domain and
process 3rd ed. American Journal of Occupational Therapy . 2014;68(Suppl. 1):S1–

44
Another random document with
no related content on Scribd:
and resourceful brain he was doubtless planning his campaign,
determining the best method of exploding his bombshell in Deanery
Street.
He paused at last in his restless pacing and turned to his
lieutenant, who knew the man too well to put any direct questions.
“Well, Sellars, we have drawn a blank with Alma Buckley, through
no fault of yours. You couldn’t have done more than you have. We
shall have to precipitate matters, and blow up Clayton-Brookes and
that young impostor, whom the world takes for his nephew, in the
process.”
Sellars would have dearly liked to have an actual inkling of what
his astute leader was planning, but he knew it was useless asking.
Lane never revealed his coups beforehand. When they were
accomplished, he was as frank as he had previously been reticent,
and would explain with perfect candour the processes by which he
had engineered them.
“Well, good-bye, Lane. Sorry the result wasn’t satisfactory. Better
luck next time. Can I get on to any other portion of the job?”
The detective thought not, at the moment; what was left he was
going to take into his own hands. But he praised his able young
lieutenant very highly for the work he had done down at Brinkstone,
the foundation on which the superstructure of the subsequent
investigations had been built.
In the meantime, while Lane was preparing his coup, Rupert
Morrice had been stealthily pursuing his line of investigation.
A passionate man by nature, he had experienced the greatest
difficulty in restraining himself on his return from the jeweller who
had told him that the supposed “birthday” necklace was a worthless
imitation. When his wife returned about five o’clock unconscious of
the tragic happenings during her brief absence, his first impulse was
to follow her up to her room, tell her what he had learned and wring
from her a confession.
But he held himself in by a great exercise of self-control. He
wanted more evidence, he wished to make sure if this was an
isolated instance or one of a series of similar transactions.
As it happened, fortune was adverse to the wrong-doer, and in the
banker’s favour. Mrs. Morrice’s friend was very unwell, and the lady
drove down to her on the two following days to cheer her up, leaving
early in the morning and returning about the same time in the
afternoon. As on the previous occasion, the maid was given a
holiday during the few hours of her mistress’s absence.
The coast therefore was quite clear for Morrice, and he took
advantage of his unique opportunities with grim determination.
Rosabelle alone in the house had an idea that something was going
on from noting the fact that she met him in the hall on one of the
mornings, carrying a small bag and wearing a very grim expression,
as if he were engaged on some urgent but disagreeable business.
In all he took some ten very valuable pieces of jewellery to the
same man for examination. The result in each case was similar, they
were all cleverly executed imitations of the original gifts he had
presented to her. That was enough for him. She had a pretty large
collection, and it might be that a great many of them were not
substitutes; that she had not so far made use of them for her secret
purposes. On those of which he was quite certain from the expert’s
evidence, he reckoned that, even selling at a greatly depreciated
price, she must have realized several thousands of pounds.
On the afternoon of the third day he was pacing his room about
five o’clock like a caged lion, feverishly awaiting his wife’s return,
waiting to confront her with the anonymous letter, and reveal to her
his verification of the charges it contained.
The clock on the mantelpiece struck five, the quarter, and the half-
hour. His face grew darker and darker, as the tide of his righteous
wrath swelled. Six o’clock struck, and no sign of Mrs. Morrice. Then
ten minutes later a telegram was brought to him which after reading
he cast angrily on the floor. It explained that her friend was very
unwell, that she was stopping the night at her house, and would
return home at lunch time to-morrow.
 The storm could not burst to-day on the devoted head of the
woman who had played so foolishly with her husband’s trust in her.
The unexpected delay incensed further the unfortunate financier,
against whom of late fate seemed to have a special grudge.
Rosabelle came in while he was fuming, to ask him for a small
cheque in anticipation of her quarter’s allowance. So preoccupied
was he with his bitter thoughts of the gross way in which he had
been deceived that he wrote the cheque like a man in a dream, and
the girl noticed that his hand trembled. When he looked up to give it
to her, she saw that his face was as black as night.
“Uncle dear, whatever is the matter?” she cried impetuously. For
some little time past she had had an uneasy feeling, one of those
presentiments which occur so often to sensitive people, that there
was trouble of some sort brewing in this household.
“Nothing the matter, my child,” he answered evasively, passing his
hand wearily across his forehead. Much as he loved his pretty niece,
much as he trusted her, he could not as yet reveal to her the cause
of his trouble, betray the woman in whom he had believed—who
bore his honoured name.
But the girl persisted. “But, dearest uncle, you are hiding
something from me. You look so strange, I am sure you are very
much moved. Have you had disturbing news?”
For a little time the unhappy man refrained from answering that
question, inspired by no spirit of girlish curiosity, but by the sincerest
and most loyal affection.
“Yes, my child, I have had bad news, very bad news, I am afraid I
am a poor dissembler,” he said at length. “Later on, under the strict
seal of secrecy, I may tell you the cause of my trouble. But not now,
not now. Run away, my precious little girl, and leave me to my black
mood.”
She dared not worry him further, although her heart was aching for
him. Nobody knew better than she the kind, tender nature underlying
that rather stern exterior. Before she obeyed him, she put her arms
round his neck and kissed him affectionately.
 “Tell me when you please, dear, in your own good time, and your
poor little Rosabelle, to whom you have always been so kind and
generous, will do her best to comfort you.”
“I know you will, you precious, warm-hearted girl.” He clasped her
hand almost convulsively. What he had found out had wounded him
to the core. Nothing hurt this strong, proud man so much as the
discovery that his confidence had been misplaced in those near to
him, that his trust in them had been abused.
“Thank heaven, I have one dear little friend in the world, one dear,
loyal little friend who has never given me a moment’s uneasiness,
who I am confident never will. But run away now, my darling. I
cannot speak yet, even to you, of what is troubling me.”
She obeyed him, and left the room wondering. The words he had
spoken had been very vague, but her quick instinct had prompted
certain suspicions of the cause of his deep perturbation. She was
confident that Mrs. Morrice was at the bottom of it. Had he found out
something to her discredit, and if so, what? Was it possible that Lane
had conceived it to be his duty to report to him that conversation
between aunt and nephew which she had overheard?
They dined alone that night, and she was sure that his deep gloom
must have been noticed by the servants who waited on them. And
she was sure it was not business matters that troubled him. He had
always boasted that he never brought home his office worries with
him, had expressed his contempt for men who did so, who had no
power of detachment. “When a man comes back to his home it is his
duty to make his family happy, and leave his business behind him,”
had been a favourite dictum of his, and to do him justice he had
always acted up to it.
After dinner they went up to the drawing-room, but he made no
pretence of being cheerful. Rosabelle asked if the piano would
disturb him. He shook his head, and she played very softly a few of
her favourite pieces. Suddenly Morrice rose, went to her, and kissed
her.
 “I am wretched company to-night, my little girl,” he said; his face
still wore its hard gloomy expression, but there was a sadness in his
voice that went to the girl’s heart. “You stay here and amuse yourself
as best you can. I am going to my study, and shall not see you again
this evening. Good-night, dear.”
Rosabelle clung to him. “Oh, uncle, can I do nothing to help you?”
He gave her a grateful smile, but shook his head obstinately, and
left the room. She played on a little after he had gone, but she was
full of troubled thoughts, and hardly knew what she was doing.
And Rupert Morrice, the great financier, the successful man of
business, respected by all who knew him, envied by many, sat alone
in his room, devoured by bitter and revengeful thoughts. What had
his wealth done for him, if it failed to buy loyalty from those who were
near to him, on whom he had lavished such kindness and
generosity?
It was only a little past eight o’clock, they had dined early as was
often their custom when they had no company. Would the weary
evening ever come to a close? But when it did, and he went to his
room, he knew he would not be able to sleep.
Suddenly the telephone bell rang. Glad of the momentary
diversion, he crossed to the instrument and unhooked the receiver.
It was Lane’s voice that was speaking. The detective was late at
his office, and it had occurred to him to ring up on the chance of
finding Morrice in and making an appointment for to-morrow
morning. He had that day, after much reflection, judged that it was
time to precipitate matters—to launch his coup.
“Ah, good-evening, Mr. Morrice. I have something of the utmost
importance to communicate to you, and the sooner the better. Can I
see you to-morrow?”
The financier’s deep voice came back through the telephone. “To-
morrow, certainly, any time you please, preferably in the morning.
But, if convenient to you, come round at once. Mrs. Morrice is away;
I am here alone.”
 Lane was rather glad to hear it. He answered that he would come
at once. What he was about to tell Morrice was bound to produce a
violent explosion, but it would not occur while he was in the house.
A few moments later the detective stood in the financier’s private
room, in a mood almost as serious as that of Morrice himself.
 CHAPTER XXI
ROSABELLE HAS A GRIEVANCE

“Y OU have something of importance to communicate to me, Mr.

Lane,” were Morrice’s first words. “Take a seat, please.”
“Something of the greatest importance, and also, I am very sorry
to say, of a most unpleasant nature. You must be prepared to receive
a great shock, Mr. Morrice.”
A grim smile fleeted across the financier’s gloomy countenance.
He had already received a very startling shock, in time he would get
inured to them.
“It concerns a young man named Archibald Brookes who, I
understand, is a frequent visitor at your house, also a member of
your family, the alleged nephew of your wife and also of Sir George
Clayton-Brookes, supposed to be her brother-in-law by the marriage
of his brother Archibald, who died in Australia, to her sister.”
At the two ominous words “alleged” and “supposed,” Morrice
looked keenly at his visitor, but he made no comment. He knew this
was a man who did not speak at random, who carefully weighed his
utterances. What was he going to hear now? Well, nothing would
surprise him after what he had already discovered for himself.
Duplicity came naturally to some temperaments.
The detective went on in his calm, even voice. “It is one of the
disagreeable duties of our profession to make unpleasant
disclosures. I made certain discoveries after taking up this case for
Mr. Richard Croxton which up to the present I have withheld from
you, out of consideration for your feelings. The time is come when
you ought to know the truth. Sir George’s family consisted of himself
and two brothers, there were no sisters. Both of these brothers died
unmarried. Therefore Sir George can have no nephew. Mrs. Morrice
was the only child of a not very successful artist; her mother lost her
life in giving her birth. Therefore the same remark applies to her,
young Archibald Brookes is no more her nephew than he is Sir
George’s. And, of course, it follows that there was no marriage
between her sister and his brother.”
Morrice’s face went very white. “You have satisfied yourself that
there is no flaw in your evidence—that it is quite reliable?”
“Unquestionably,” was the detective’s answer. “My evidence with
regard to your wife is her father’s statement made frequently in the
hearing of several persons. As to Sir George’s brother, a colleague
of mine in Australia made exhaustive inquiries on my behalf and
found that Archibald Brookes senior had never married. I have also
got further evidence from an old friend of mine at Scotland Yard who
has had Sir George and his supposed nephew under observation for
some time; that the young man was brought up under the charge of
a woman named Alma Buckley, a not very prominent member of the
music-hall profession, up to the period when Sir George adopted him
and put about this story. Further, that at the time of his adoption
young Archie Brookes was occupying an insignificant commercial
post in the city of London. Of course, you know nothing of all this?”
The words were not put in the form of a question, but rather
conveyed the assumption that it was impossible the financier could
have any knowledge of such a gross deception.
But they brought to the surface at once that fiery temper which up
to the present he had kept in check.
“What do you take me for, sir? My greatest enemy can never say
of me that I have been guilty of a mean or dishonourable action. Do
you think for a moment, from any motives whatever, even from a
desire to shield one so closely related to me, I would be a party to
such a shameful fraud?”
Lane hastened to pour oil on the troubled waters. “Pardon me, Mr.
Morrice, I did not hint at such a thing. I said that, as a matter of
course, you knew nothing about it.”
“It was almost unnecessary that you should say even as much as
that,” growled Morrice, only half appeased. His mind was quick
enough when he chose to exercise it. This man had been rendered
suspicious and distrustful of everybody by his calling, and the sinister
secrets he discovered in the pursuit of it. He had half suspected, or
at any rate thought it within the bounds of possibility, that Morrice
might have some inkling of what had been going on, and he had
chosen this way of provoking a definite disclaimer.
“There are other things it is my duty to tell you,” went on the
detective smoothly; he was not going to take any further notice of
that angry outburst. “For some long time past Mrs. Morrice has been
in the habit of supplying the young man with money. I cannot
estimate the amount that has passed into his hands, but judging
from his extravagant habits, I should say it must be a considerable
sum, much more than the lady could afford if she were to maintain
her position as the wife of a wealthy man.”
A lightning inspiration came to the unfortunate financier. “Am I not
right in saying that you sent me an anonymous letter on this very
subject?”
Lane felt it was useless to prevaricate. “I did. I may be wrong, but I
felt it was the best way to set you on the track. I thought it would be
very painful for you to be warned in a more open and direct way. I
trust that the suspicion I threw out was not justified.”
He said this with a very good show of concern, although he was
certain he had not fired that shot at random. Mrs. Morrice’s avowal
that she had been half ruined, and that it could not go on, had
convinced him that her assistance to young Brookes had not been
confined to a few hundreds out of her annual allowance—these
would have gone no way with such a determined prodigal.
For the first time in his life, Rupert Morrice’s proud head drooped
in deep humiliation. It was terribly degrading to him to listen to the
detective’s merciless recital, to know that the treachery of the woman
who bore his name, to whom he had given an honoured and assured
position, was, as it were, the common property of others.
“Alas,” he said, in a voice from which every trace of anger had
fled, which only expressed feelings of the most unutterable sadness.
“Your suspicions have been fully justified. From whence did you get
all this information that enabled you to make such an accurate
diagnosis of what was happening?”
But Lane was very staunch, and as high-minded as a man could
be in the trying circumstances of such a profession. He would
certainly not give Rosabelle away, for if he did Morrice would be sure
to think she should have come to her uncle first and discussed with
him the propriety of going to Lane at all. He had in a manner rather
stolen a march upon her, but she should not suffer.
“You must excuse me, Mr. Morrice, if I am unable to answer that
very natural question. I always like to be as frank as possible with my
clients, but there are times when, from motives perfectly satisfactory
to myself, I am unable to reveal the means by which I obtain our
information.”
Morrice made no reply. He would have dearly loved to know, but
he was fair-minded enough to appreciate the detective’s excuse.
Probably he had obtained his knowledge from some prying servant
in the house who had kept a close watch upon his wife. Lane was
not the man to despise the assistance of any instrument, however
humble. Not for one moment did it occur to Morrice that his niece
was implicated in the matter.
“And now, Mr. Morrice, I don’t wish to ask you more than I can
help, for I can fully understand how you must be suffering, and how
painful it must be for you to talk over these things with a stranger.
But you say that my suspicions are confirmed—in short, you have
made your investigations and found what I surmised, that a
considerable number of jewels have been realized, and imitations
put in their place. Am I right in saying that it means a large sum?”
“Several thousands of pounds, even taking into account the
depreciated price which could be obtained for them,” was Morrice’s
answer.
“I guessed it. But I doubt if it has all gone into the pockets of young
Brookes. Mind you, I have no actual evidence of what I am going to
say—it is, if you like, absolute theory—but Sir George is in this game
and has engineered it from the beginning. They are in this together,
depend upon it. Which gets the better share I cannot say; I should
fancy the older and more experienced rogue.”
“I daresay you are right,” said Morrice wearily. “We know him to be
a rogue from his being a party to this nephew fraud. And yet he
poses as a rich man, although Mrs. Morrice has more than once
dropped a hint that he is fast dissipating his money at the gaming-
table.”
So that was his vice attributed to him by one who knew too well,
thought the detective. That accounted for his being well-off one day
and a pauper the next.
After exacting from Morrice a promise that he would not use the
information in any way, Lane told him what he had picked up from
his friend at Scotland Yard, viz. that Sir George was strongly
suspected of being in league with high-class crooks.
The unhappy financier sat crushed and humbled by all these
terrible revelations. His world seemed falling about his ears—his
wife, of whose integrity he had never entertained the slightest
suspicion, the friend and confidant, the associate in a vile deception,
of a man of good birth and position strongly suspected of being
engaged in criminal enterprises. He had never taken kindly to Sir
George; he was too plausible and artificial for his liking. For the
supposed nephew he had entertained a good-natured contempt. But
he had never harboured the faintest idea that they were a couple of
base scoundrels.
Lane rose to go. Later on he would have to say more to Mr.
Morrice, but to-night he had said enough.
“I think you told me over the telephone that your wife was away. I
suppose you have said nothing to her yet?”
“Nothing,” answered Morrice, with a face like granite. “I have not
had time. It was only to-day that I got the full amount of proof I
wanted. If it had only concerned itself with one article of jewellery, or
a couple at the outside, I might have thought she had sold them to
defray some gambling debt, some bills that she was ashamed to tell
me about.”
“Quite so, Mr. Morrice. But I take it when your wife returns you will
confront her and extort a confession.”
Nothing could have been grimmer than the husband’s expression
as he answered. It was easy to see he would be as hard as flint
when his righteous wrath was aroused—pitiless, unforgiving.
“Of course. And please, Mr. Lane, do not speak of her as my wife.
The law, I know, will not sever the tie for such a cause as this, but so
far as I am concerned that tie is already severed. She returns to-
morrow, and in another twenty-four hours the same roof will not
shelter us. I shall not leave her to starve; I shall make her a decent
allowance, and she can live out the rest of her shameful life in the
society of friends congenial to her—this scoundrel Clayton-Brookes
and the rascal whose aunt she pretends to be—perhaps the woman
Alma Buckley, of whom I have never heard.”
“And whom she visits secretly,” interposed Lane. “I have had her
watched and know that for a fact.”
“Ah, I am not surprised; in fact, nothing would surprise me now.
Mark you, I shall not publish to the world the story of her treachery.
Why should I fill the mouths of curious fools? It would not undo my
wrongs nor alleviate my bitter humiliation. I shall agree with her to
concoct some tale of incompatibility extending over many years and
culminating in a separation absolutely necessary for the peace of
mind of both. The truth will be known for certain to two people, you
and myself, perhaps a third—my niece Rosabelle Sheldon. You, I am
convinced, Mr. Lane, are a man of discretion and will keep your
knowledge to yourself.”
Lane assured him that the secrets of all his clients were sacred to
him. One last question he put before he left.
“You will make her confess who this so-called Archie Brookes
really is?”
And Morrice’s voice was as hard as iron as he answered: “You
may rely upon me to do my best. Good-night, sir. What I have
learned through your masterly activities has been inexpressibly
painful, but thank heaven I know at last the foes in my own
household. I shall no longer live in a fool’s paradise.”
Shortly after Lane’s departure he went to his room, but try as he
would, sleep refused her kindly solace. The man had been shaken to
the very foundation of his being.
On his way out Lane found Rosabelle waiting for him in the hall as
on a previous occasion; she had heard of his visit from one of the
servants.
“Why are you here to-night?” she whispered. “Has anything of
importance happened?”
“A great deal,” Lane whispered back. “It was not till the last
moment I made up my mind to come, but certain things happened
which rendered it necessary to hasten matters. I have not time to tell
you now, it would take too long. Slip down to my office to-morrow
morning as early as you can.”
Much wondering, the girl promised she would be there as near ten
o’clock as possible.
“And just one last word, Miss Sheldon. I have told your uncle that
young Brookes has been sponging on Mrs. Morrice, and much has
been found out. But your name has not been brought in. Forget all
about that conversation you told me of. Best, if your uncle should
question you to-night or to-morrow, to dismiss it from your mind, to
appear surprised as you would have been if you had never
overheard it. I will explain to-morrow. Good-night. I will not stop a
second longer; he might come out any moment and surprise us.”
Restless and impatient for that to-morrow, the girl’s sleep was little
less broken than her uncle’s. What was Lane going to tell her? Was
he going to be perfectly frank after all?
She was there a little before the time appointed, but Lane was
disengaged and saw her at once. He made a clean breast of it this
time, and told her everything that had happened from the beginning
of his investigations.
 “I may as well tell you that I went over to Mr. Croxton the other day
and told him all that I knew. And I am afraid you will never forgive
me, Miss Sheldon, when you know that I made it a condition of my
confidence that he should keep it to himself till I removed the
embargo. But I had my reasons, reasons which I can’t very well
explain and which, I am sure, would be unconvincing to you.”
Rosabelle was very shocked at her aunt’s duplicity and disgusted
when she learned the truth about Archie Brookes. But she was not
so preoccupied with the emotions to which his recital gave rise as
not to be more than a little hurt that Lane had kept her in the dark
longer than anybody else.
“I suppose the truth is you have a contempt for women, and place
no trust in them?” she said resentfully.
The detective made the most diplomatic answer he could in the
circumstances, apparently with a satisfactory result. Anyway, they
parted good friends.
 CHAPTER XXII
HUSBAND AND WIFE

M ORRICE stayed in the next day waiting for the return of his wife
from her country visit. She was to arrive home in time for lunch.
About twelve o’clock Rosabelle came into his room; she had just
returned from her visit to Lane.
“Oh, uncle, there is a strange young man in the hall with a letter for
auntie. He says his instructions are to give it into her own hands. He
was told that she would be back before lunch-time, and he said he
would wait. He seems rather mysterious. Would you like to see
him?”
Morrice nodded his head and strode into the hall, where he found
standing a sallow-faced young fellow, quite a youth, with a tall
footman mounting guard over him, as it were, on the look-out for
felonious attempts.
“What is it you’re wanting, my man?” he asked roughly. He did not,
any more than his servant, like the appearance of the fellow, who
seemed a furtive kind of creature with a shifty expression.
The furtive one explained hesitatingly in a strong cockney accent:
“A letter for Mrs. Morrice, sir. I was to be sure and give it into no
hands but her own.”
Something very suspicious about this, certainly. Morrice thought a
moment, pondering as to the best way to proceed with this rather
unprepossessing specimen of humanity. He had a common and
unintelligent kind of face, but he looked as if he possessed a fair
share of low cunning.
A week ago Morrice would have thought nothing of such an
incident; he would have told the man to come later when his wife
would have returned. But recent events had developed certain
faculties and made him anxious to probe everything to the bottom, to
scent mystery in every trifling act.
“Who sent you with the letter, and gave you such precise
instructions, my man?”
The answer came back: “Mrs. Macdonald, sir.”
Morrice’s brows contracted. He was as sure as he could be of
anything that the man was telling a lie.
“Mrs. Macdonald, eh? Where does she live?” was the next
question.
This time the answer did not come as readily; there was a
perceptible hesitation. Morrice guessed the reason as rapidly as
Lane himself would have done. The sender of the letter had primed
the messenger with a false address. Out of loyalty to his employer,
he had been cudgelling his rather slow brains to invent one.
“Number 16 Belle-Vue Mansions, Hogarth Road, Putney,” he said,
speaking after that slight hesitation with a certain glibness that was
likely to carry conviction.
Morrice did not know of any woman of the name of Macdonald
amongst his wife’s acquaintances. Still, that might mean nothing; it
might be a begging letter which the writer had taken these unusual
means of getting to her.
“Let me have a look at the envelope,” demanded Morrice.
The shabby, furtive-looking young fellow began to appear a bit
uneasy, with the dictatorial master of the house regarding him with
anything but a favourable eye, the young girl standing in the
background who seemed no more friendly, and the tall footman
standing before the door, barring a sudden exit.
“Beg pardon, sir, but my orders was most precise to only give it
into the hands of the lady herself.”
Morrice saw that he must change his tactics. He took from his
pocket a couple of treasury-notes which made a pleasant crackle as
he flourished them before the youth’s face.
 “You see these, don’t you? I take it you haven’t got too much
money. They are yours if you let me see the envelope, only the
envelope. I don’t want to take your letter,” he added with a cunning
that was quite a recent development of his character. “As soon as
I’ve seen that you can go out and come back in an hour when Mrs.
Morrice will have returned home.”
The youth fell into the trap. Slowly he produced from his pocket
the letter which he held gingerly between his finger and thumb for
the inspection of the superscription on the envelope. Quick as
lightning, Morrice snatched at it and put his hand behind his back,
throwing at him with his disengaged hand the treasury-notes he had
promised.
“Now get out of this, my fine fellow, and never dare to come to this
house again with such an impudent message. Tell Mrs. Macdonald
of Putney, or whoever it may be that sent you, that Mr. Morrice
insisted on having that letter, and that it will be given to Mrs. Morrice
on her return.”
The furtive creature slunk away; after that drastic action he had no
more fight in him. Morrice remembered the waiting footman whose
impassive countenance did not betray any surprise at this rather
extraordinary scene over what seemed a trifle, and turned to his
niece with a smile that was decidedly forced.
“Never heard of such cheek in my life. Some impudent mendicant,
I expect. By gad, they are up to all sorts of dodges nowadays.”
He marched back into his own room, and Rosabelle went to hers
to think over what this action of her uncle’s meant. It was evident he
attached considerable significance to that letter which was only to be
delivered into Mrs. Morrice’s hands. What was he going to do with it?
Well, it did not much matter. He knew enough now, and in a very
short time the bolt would fall, according to what Lane had told her.
Morrice had made up his mind what to do with it. Never in his life
had he opened correspondence not intended for his perusal; never
again, he hoped, would he be forced to resort to such a mean action.
But everything was fair now; it was justifiable to meet cunning with
cunning, duplicity with corresponding duplicity.
He opened that letter with the sure instinct that it would be of help
to him, and he was not deceived. There was no address and no
signature. Evidently the handwriting was too well known to Mrs.
Morrice to require either. It was very brief; but even if he had not
known what he already did, it would have revealed to him a great
portion of what he had lately learned.
“A young man has been to see me, says he is not a
professional detective, and doesn’t look like one, but very
keen. Wanted to get out of me all about your early life. Of
course, he got nothing. The worst is he seems to know
something about Archie, knows that I brought him up. Be
on your guard; I am afraid trouble is brewing.”
He put this damaging missive in his pocket along with the
anonymous letter, and presently went up to his wife’s room to await
her return to the home which, he had resolved, should no longer
shelter a woman who had deceived him so grossly. He guessed at
once the writer of this warning note—it could be none other than
Alma Buckley, the friend of her youth. The reference to her having
brought up the man known as Archie Brookes proved that beyond
the possibility of doubt.
How long it seemed before the minutes passed and the door
opened to admit the familiar figure! Preoccupied with her own
thoughts, Mrs. Morrice hardly looked at her husband as she
advanced to give him the perfunctory kiss which is one of the
courtesies of a placid and unemotional married life.
But when he drew back with a gesture of something like
repugnance from the proffered caress, she noted for the first time the
terrible expression on his face, and was overcome with a deadly
fear.
“What is the matter? Why are you looking like that?” she gasped in
a trembling voice.
 Consumed inwardly with fury as Morrice was, he exercised great
control over himself. He knew that he would put himself at a
disadvantage if he stormed and raged; he must overwhelm this
wretched woman with the pitiless logic of the facts he had
accumulated. He must act the part of the pitiless judge rather than
that of the impassioned advocate.
He advanced to the door and turned the key, then came back to
her and pointed to a chair. There was a cold and studied deliberation
about his movements that filled her guilty soul with a fearful terror.
“Sit there while I speak to you,” he said in a harsh and grating
voice. “You have much to account to me for. Read that.”
He drew the anonymous letter from his pocket and flung it in her
lap.
Like one dazed, she drew it from the envelope with trembling
fingers, and very slowly, for her thoughts were in terrible confusion,
mastered its accusing contents. Then she looked up at him with a
face from which all the colour had fled, leaving it ghastly to look at.
“It is a lie,” she stammered in a voice scarcely above a whisper.
“It is the truth,” he thundered, “and you are as shameless in the
hour of your detection as you have been in your career of fraud and
deceit.”
“Prove it,” she cried faintly, still feebly trying to oppose his
gathering anger.
“You have lived with me a good many years,” he said witheringly,
“and yet you know so little of me as to think I should speak like that if
I were not sure I was on firm ground. And yet perhaps you have
some excuse. I have been a blind fool so long that you were justified
in your hopes I should continue blind to the end. Well, that letter
opened my eyes. Your fortunate absence gave me facilities that it
might have been difficult to create. I have taken several of the most
valuable articles in your collection and had them examined. Need I
tell you the result? Your guilty face shows plainly enough that you
need no telling.”
 And then her faint efforts at bravado broke down.
“Forgive me,” she moaned. “I yielded in a moment of temptation.
Many women have done the same; they were my own property after
all,” she added with a feeble effort at self-justification.
That answer only provoked him the more. “A moment of
temptation,” he repeated with scornful emphasis. “Rather many
moments of temptation. This has been going on for years; these
things were realized piece by piece. And now tell me—for I will have
the truth out of you before you leave this room—where have these
thousands gone, what have you got to show for them?”
It was a long time before she could steady her trembling lips to
speak, and when she did the words were so low that he could only
just catch them.
“Nothing. I have been a terribly extravagant woman. I have lost
large sums of money at cards. You never guessed that I was a
secret gambler—there is not a year in which I have not overstepped
my allowance, generous as it was. I was afraid to come to you.”
He silenced her with a scornful wave of the hand. “Lies, lies, every
word you have uttered! You have done none of these things you
pretend; it is an excuse you have invented in your desperation.”
He drew himself up to his full height and pointed a menacing finger
at the stricken woman. “Will you tell me where these thousands have
gone? No, you are silent. Well then, I will tell you—not in gambling
debts, not in unnecessary personal luxuries—no, if it were so I would
be readier to forgive. They have gone to support the extravagance of
that wretched idler and spendthrift who is known by the name of
Archie Brookes. Do you dare to deny it?”
She recognized that he knew too much, that further prevarication
was useless. “I do not deny it,” she answered in a moaning voice.
And after a little pause he proceeded with his denunciation.
“It is as well that you do not, seeing I know everything. Well, bad
as that is, there is worse behind. I have learned more; I know that
you, in conjunction with that smooth scoundrel Clayton-Brookes,